Endovascular Therapy for AIS Beyond 24-Hour Window May Be Safe and Effective

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Endovascular Therapy for AIS Beyond 24-Hour Window May Be Safe and Effective

Sheila Jacobs

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June 26, 2023

Endovascular therapy for AIS, performed in patients presenting beyond 24 hours, was safe and associated with favorable outcomes.

The use of endovascular therapy (EVT) in patients with very late-window (ie,
>24 hours) acute ischemic stroke (AIS) may be safe and effective, according to findings from a systematic review and meta-analysis published in JAMA Network Open.

Although prior randomized controlled trials (RCTs) have supported the utilization of EVT as the standard of care for patients who experience an AIS associated with large vessel occlusion in the late window (ie, 6 to 24 hours), the efficacy and safety of EVT beyond 24 hours remain to be elucidated.

Researchers sought to explore outcome distributions following EVT used for very late-window AIS by conducting a systematic review and meta-analysis.

The primary outcome of interest was functional independence, which was evaluated according to scores on the 90-day modified Rankin scale (mRS) of 0 to 2. Secondary outcomes of interest included thrombolysis in cerebral infarction (TICI) scores (2b to 3 or 3), symptomatic intracerebral hemorrhage (sICH), 90-day mortality, early neurologic improvement (ENI), and early neurologic deterioration (END).

These results suggest that EVT may be safe and associated with improved outcomes for very late-window AIS, although RCTs and prospective, comparative studies are needed to determine which patients may benefit from very late intervention.

The researchers selected a total of 7 studies that included 569 participants for the meta-analysis. Of the 7 studies, 6 evaluated data from prospective databases and 4 were multicenter analyses. Among the studies included, the sample sizes ranged from 21 to 185 participants. Regarding the quality of the 7 studies chosen, 6 were deemed to be of good quality and 1 was determined to have fair quality.

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Among the 569 participants involved in the meta-analysis, 35 individuals received intravenous thrombolytic agents. The mean participant age was 68.9 years (95% CI, 65.9-72.2 years). Mean baseline National Institutes of Health Stroke Scale (NIHSS) score was 13.6 (95% CI, 11.9-15.5); the mean Alberta Stroke Program Early CT Score (ASPECTS) score was 7.9 (95% CI, 7.2-8.7). Further, the mean time from well and/or onset to puncture was 46.2 hours (95% CI, 32.4-65.9 hours).

Overall, 6 of the 7 studies that involved 463 participants reported on the primary outcome — that is, functional independence at 90 days using mRS scores of 0-2. The frequency reported with the 90-day mRS was 32.0% (95% CI, 24.7%-40.2%). Significant heterogeneity, however, was observed among the pooled studies (P =.01).

Frequencies reported for the secondary outcomes were as follows:

• TICI scores of 2b to 3: 81.9% (95% CI, 78.5%-84.9%)
• TICI scores of 3: 45.3% (95% CI, 36.6%-54.4%)
• Rates of sICH: 6.8% (95% CI, 4.3%-10.7%)
• Rates of 90-day mortality: 27.2% (95% CI, 22.9%-31.9%)
• Rates of ENI: 36.9% (95% CI, 26.4%-48.9%)
• Rates of END: 14.3% (95% CI, 7.1%-26.7%)

Several limitations of the meta-analysis warrant mention. A very low number of studies fulfilled the inclusion criteria. Additionally, there were certain outcomes that were not reported in all of the studies. Further, the meta-analysis did not include a comparator group that was treated with medical management, since many of the included studies had no comparison group. Also, since the researchers did not have access to any patient-level data, this limited the analysis that they were able to perform.

“These results suggest that EVT may be safe and associated with improved outcomes for very late-window AIS, although RCTs and prospective, comparative studies are needed to determine which patients may benefit from very late intervention,” the researchers concluded.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

References:

Kobeissi H, Ghozy S, Adusumilli G, et al. Endovascular therapy for stroke presenting beyond 24 hours: a systematic review and meta-analysis. JAMA Netw Open. 2023;6(5):e2311768. doi:10.1001/jamanetworkopen.2023.11768