Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis

 So for these selected patients you have the same failure to get to 100% recovery as the early patients. Good to know you're accepting failure as the normal option for stroke survivors. Do you tell your patients ahead of time that you will fail to get them 100% recovered  but that is ok just because it is too hard to solve stroke?

Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis

Ye Zhongxing^1†, Liu Zhiqiang^1†, Wang Jiangjie², Chen Qing³, Zhang Jinfeng¹, Weng Chaoqun¹ and Li Feng^4*

• ¹Department of Neurosurgery, Fujian Sanbo Funeng Brain Hospital, Fuzhou, China
• ²Department of Neurosurgery, Linyi Central Hospital, Linyi, China
• ³Department of Pathology, Linyi Central Hospital, Linyi, China
• ⁴Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou, China

Background: There is considerable evidence on the benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) within 6 h after symptom onset. However, uncertainties remain regarding EVT efficacy beyond 6 h after symptom onset. We undertook a meta-analysis to assess the efficacy and safety of EVT in patients with AIS >6 h after symptom onset.

Methods: We searched PubMed, EMBASE, and Chinese Biomedical through July 2019. We included studies involving early (≤6 h) vs. delayed (>6 h) EVT in selected patients with AIS, based on radiological evaluation criteria. Functional independence, successful recanalization, mortality, and symptomatic intracranial hemorrhage (sICH) rates were assessed.

Results: Eight articles, with 3,265 patients who had undergone early EVT and 1,078 patients who had received delayed EVT, were included in the meta-analysis. Patients treated with early EVT showed a similar proportion of functional independence at 90 days [odds ratio (OR) = 1.14, 95% confidence interval (CI) = 0.926–1.397, P = 0.219; I² = 36.2%, P = 0.128] as those treated with delayed EVT. Delayed EVT was also associated with no significant difference in mortality (OR = 1.015, 95% CI = 0.852–1.209; P = 0.871; I² = 0.0%, P = 0.527), successful recanalization (OR = 1.255, 95% CI = 0.923–1.705; P = 0.147; I² = 60.5%, P = 0.009), and sICH (OR = 0.976, 95% CI = 0.737–1.293; P = 0.871; I² = 0.0%, P = 0.742) rates compared with early EVT.

Conclusions: Among selected patients with AIS, delayed EVT showed comparable outcomes in functional independence, recanalization, mortality, and sICH rates compared with early EVT.

Introduction

Acute ischemic stroke (AIS) is one of the leading causes of mortality and long-term disability globally (1). In recent years, overwhelming evidence has demonstrated the benefits of endovascular thrombectomy (EVT) for AIS within 6 h after symptom onset (2). Six randomized controlled trials (RCTs) (MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT, SWIFT-PRIME, and THRACE) concerning EVT for large vessel occlusion (LVO) in the anterior circulation established this therapy as a new standard for AIS treatment (1–3). However, uncertainties remain regarding the efficacy and safety of EVT for patients with AIS and LVO when performed >6 h after symptom onset (4). Recent American Heart Association/American Stroke Association (AHA/ASA) and European Stroke Organization (ESO) guidelines have recommended that EVT should be performed within 6 h of symptom onset for patients with AIS (5, 6).

However, notably, two recent RCTs, namely, the DAWN trial and the DEFUSE trial, have challenged previous understandings. In patients with a mismatch between deficit and infarct, the DAWN trial demonstrated that EVT was beneficial 6–24 h after symptom onset when compared with standard medical care only (7). Perfusion or advanced computed tomography (CT) perfusion was also a criterion for patient selection in the DEFUSE-3 trial (8). The results indicated that EVT plus standard medical care for patients with AIS 6–16 h after symptom onset was associated with more favorable efficacy and safety than standard medical therapy alone (8). The aforementioned two RCTs emphasized the importance of the tissue window in saving potentially salvageable brain tissue. Hacke (9) reported that the usual 6-h time window for EVT should be replaced with a “tissue window.” These findings would appear to indicate that the current time window needs to be reconsidered.

Furthermore, prior to these RCTs, several studies had challenged the 6-h time window. Some retrospective studies have shown that patients with AIS who had been treated with delayed EVT (>6 h after symptom onset) showed comparable efficacy and safety compared with patients with AIS who had been treated with early EVT (within 6 h after symptom onset) (10, 11). These studies provided further evidence for delayed EVT in patients with AIS that needs consideration. Therefore, we undertook a meta-analysis to assess the efficacy and safety of EVT for patients with AIS who had been treated >6 h after symptom onset.

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