Abstract
Background: The 2018 ASA guidelines recommend endovascular stroke treatment (EVT) for patients who meet DEFUSE 3 (D3) trial criteria within 6-16 hrs and those who meet DAWN criteria within 6-24 hrs of last known well (LKW). Recommendation to use more restrictive DAWN and not D3 criteria between 16 and 24 hrs is not strictly followed in clinical practice. Using the prospective multi-institutional cohort study, “Blood Pressure after EVT (BEST),” we determined the frequency and outcomes of EVT-treated patients within the 16-24 hrs of LKW who met D3 but not DAWN criteria. Methods: BEST enrolled consecutive EVT-treated adult patients with ICA, M1, or M2 occlusions at 12 comprehensive stroke centers from 11/2017 to 7/2018. D3-but not DAWN-eligible patients were defined as those with ICA/M1 occlusions, a mismatch volume 15cc, and any of the following: 1) NIHSS 6-9, 2) infarct core 51-70 cc, 3) age 80 yrs and infarct core 21-70 cc, or 4) NIHSS 11-19 , age <80 yrs and infarct core 31-70 cc. We compared mTICI score, symptomatic ICH, discharge disposition, and 90-day mRS in patients who met D3 but not DAWN criteria (16-24 hrs) to those who strictly met criteria for 1) D3 (6-16 hrs) and 2) DAWN (6-24 hrs). Results: Of 457 patients, 159 (35%) underwent EVT within 6-24 hrs (mean age 66 yrs; 51% female; median NIHSS 14 [IQR: 9, 19]), and 26 (16%) were within 16-24 hrs. Of the 16-24 hr group, 8 (31%) met D3 but not DAWN criteria. Proportion of mTICI 2b-3, symptomatic ICH, and discharge disposition distribution were not different compared those who met full D3 or DAWN criteria. 90-day functional outcomes were better than those who met the full DAWN criteria (table). Conclusion: One in three patients treated with EVT within 16-24 hrs of LKW at major academic comprehensive stroke centers did not meet current guideline recommendations (DAWN criteria). In this small sample size study, safety and outcome results are comparable to those who met guideline criteria. Dedicated studies are needed to confirm this finding.
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