Novel selection paradigms for endovascular stroke treatment in the extended time window

More importantly, what are your protocols for 100% recovery  for those that don't meet the selection criteria? You're basically letting billions upon billions of neurons die.  You do realize that the only goal in stroke is 100% recovery  and to leave no survivor behind?

Novel selection paradigms for endovascular stroke treatment in the extended time window

1. http://orcid.org/0000-0003-1601-5912Mehdi Bouslama1,2,
2. Diogo C Haussen1,2,
3. Gabriel Rodrigues1,2,
4. Clara Barreira1,2,
5. Michael Frankel1,2,
6. Raul G Nogueira1,2

1. Correspondence to Dr Raul G Nogueira, Neurology and Interventional Neuroradiology, Emory University, Atlanta, GA 30303, USA; rnoguei@emory.edu

Abstract

Background and purpose The optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established.

Methods Review of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6–10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6–10.

Results 310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome.

Conclusions ASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes(So failure to get 100% recovered?) as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.