Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States.

Introduction: Endovascular thrombectomy (ET) is an effective but time sensitive treatment of acute ischemic stroke. Time from Emergency Department (ED) arrival to start of ET (door-to-puncture time, DTPT) is a modifiable metric. One of the most time consuming steps in prolonging DTPT is identification of large vessel occlusion (LVO) by CT angiography (CTA). BEST-MSU is a prospective multicenter comparative effectiveness study of tPA-eligible patients managed on a mobile stroke unit (MSU) vs Emergency Medical Services (Standard Management, SM). After discovering that DTPT was greater than 60 minutes in both groups at three BEST-MSU centers in 2018, we began to routinely obtain CTA on the MSU and directly alert the ET team at receiving hospitals if a LVO was identified. We hypothesized this would shorten DTPT by over 30 minutes. Methods: In this single center experience, we compared the median (interquartile range, IQR) DTPT and MSU on-scene time for MSU patients having on-board CTA and then ET from 9/2018 to 7/2019 to corresponding MSU ET patients (excluding any that had on-board CTA) from 8/2014 to 8/2018. All CTAs were completed after tPA bolus and during tPA infusion on a Ceretom 8 slice scanner with OptiStat hand injector. All imaging occurred on-scene with the MSU stationary. Consent was obtained for all patients and strict radiation safety guidelines followed. Results: 13 consecutive patients having CTA on-board the MSU and then ET were compared to 84 patients in the pre-on-board CTA group. Baseline characteristics including median NIHSS score (20 in both groups) and frequency of tPA (85% on-board CTA vs 89% pre-on-board CTA) were comparable. Median DTPT was 60 minutes shorter with on-board CTA and direct notification of the interventional team from the MSU; 34 minutes (IQR 30-57) vs 94.5 minutes (IQR 69.75-117.25) (p < 0.001). Despite the additional time to obtain the CTA on the MSU, on-scene time was only slightly prolonged and did not offset the reduction in DTPT (on-board CTA 30 minutes (IQR 28-33) vs pre-on-board CTA 27 minutes (IQR 23-31) (p = 0.01). Conclusion: Pre-hospital identification and notification of LVO by a MSU allows a one hour reduction of DTPT, and can be utilized to establish a direct to angiosuite protocol.

Should Primary Stroke Centers Perform Advanced Imaging?

Introduction: The impact of a Mobile stroke unit (MSU) on access to Endovascular Thrombectomy (ET) is a pre-specified BEST-MSU sub-study. On the MSU, ET decision-making steps such as CT, neurologic exam, and tPA treatment are completed prior to Emergency Room (ER) arrival. We hypothesized that such pre-ER assessment of potential ET patients on a MSU improves metrics. Methods: BEST-MSU is a prospective comparative effectiveness study of MSU vs Standard Management by Emergency Medical Services (SM). We compared ER door-to-puncture-time (mins, DTPT) among the following groups of MSU and SM patients: all ET patients (ETP), ET patients post-tPA (ETT), and ET patients post-tPA meeting thrombolytic adjudication criteria (ETTA) over the first four years of the study. Results: There were 161 ETP (67 SM, 94 MSU), 140 ETT (55 SM, 85 MSU), and 126 ETTA (50 SM, 76 MSU) patients. DTPT was shorter for MSU patients (ETP 89 vs 99, p=0.01; ETT 93 vs 100, p=0.03; ETTA 93 vs 99.5, p=0.03). From 2015 to 2018, DTPT decreased at a faster rate for SM compared with MSU-managed patients, improving by about an hour (Figure). Conclusion: Pre-ER ET evaluation on a MSU results in faster DTPT. Since 2015, dramatic improvement in ER ET metrics has attenuated this difference. However, DTPT of 90-100 mins in all groups indicates substantial room for improvement.

Introduction: Randomized clinical trials have demonstrated efficacy and safety of endovascular thrombectomy (EVT) among patients presenting up to 24 hours of last known well (LKW). Recent reports have suggested EVT could result in better functional outcomes with acceptable risk profile even in patients presenting beyond 24 hours of LKW, but exploration of the role of EVT in elderly patients presenting beyond 24 hours is limited. Methods: We aimed to evaluate functional and safety outcomes for EVT in patients with age ≥80y with a large vessel occlusion (LVO) beyond 24 hours of LKW, from a pooled, international cohort (17 centers across US, Spain, Australia and New Zealand) between 7/2012 and 12/2021. Primary outcome was a shift on modified Rankin Scale score at 90-day follow-up. Results: Of 301 included, 88 (53 EVT, 35 medical management MM) were aged ≥80y, with 57 females and 21 nonagenarians. Median(IQR) NIHSS - 17.5 (11-22),CT ASPECTS - 7(4-9), ischemic core 5.5 (0-26) ml. Overall, as age increased, clinical outcomes worsened (acOR: 0.64, 95% CI: 0.55-0.74, p<0.001 per 10 year increment). However, EVT was associated with a shift towards better functional outcome among patients with age≥80y (acOR: 8.31, 95% CI:2.80-24.68, p<0.001) and among patients with age<80y (acOR: 2.11, 95% CI: 1.22-3.66, p=0.008), with a significant interaction (p-int:0.047 – fig1) suggesting higher improvement within octogenarians. Estimates of Functional independence (EVT: 27% vs MM: 6%, aOR: 11.86, 95% CI: 1.75-80.28, p=0.011) and mortality (EVT: 42% vs MM: 71%, aOR: 0.16, 95% CI: 0.05-0.52, p=0.003) also favored EVT, with similar results obtained using inverse probability of treatment weights [Table 1]. 4 patients within EVT arm and no patients within MM arm developed symptomatic ICH. Among octogenarians receiving EVT, lower presentation NIHSS (aOR: 0.77, 95% CI: 0.64-0.92, p=0.003 per point increment) and presence of M2 occlusion (aOR: 11.01, 95% CI: 1.15-105.36, p=0.037 were independently associated with functional independence at 90-day follow-up), but not time to procedure (aOR: 0.99, 95% CI: 0.96-1.02, p=0.64, fig2). Conclusions: In a pooled international cohort of octogenarians who presented beyond 24 hours with an LVO, EVT was associated with better functional outcomes, higher functional independence and lower mortality. Lower stroke severity and presence of M2 occlusion were independently associated with functional independence at 90-day after EVT.

Introduction There has been a growing body of literature in recent years suggesting the safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) from distal vessel occlusion (DVO). Limited data is available regarding the risks and benefits of EVT in this patient population, especially when comparing the early window (6 hours from LKW) to the extended window (6‐24 hours from LKW). We aim to study this further. Methods We queried our stroke registry, a prospectively maintained database of AIS patients who presented from December 2014 to July 2023, and isolated patients with DVO who underwent EVT. DVO was defined as M2, M3, M4 occlusion, ACA occlusion, and/or PCA occlusion. We then further subdivided this into two groups, patients within the early window, and patients within the extended window. We compared characteristics between these groups using univariate analysis. We additionally performed a multivariable logistic regression analysis adjusted for Alberta Stroke Program Early CT Score (ASPECTS), National Institutes of Health Stroke Scale (NIHSS) score, age, sex, and use of intravenous (IV) thrombolysis to investigate whether or not extended window thrombectomy was associated with worse outcome. Our primary outcomes were modified Rankin Score (mRS) at discharge and at 90 days. Results Total of 290 patients had DVO and underwent EVT. Of these, 214 had all relevant data. 147 (68.7%) underwent EVT in the early window and 67 (31.3%) received EVT in the extended window. Mean age was 72.3 (±14.4). There were more women in the extended window 51.5% vs 44.8% (χ² = 20.57, p‐value < 0.001). No significant difference was observed in the average NIHSS between early (13.7) and extended (13.9) windows (t=‐0.44, p=0.66). Similarly, the median ASPECTS score was comparable between early (9.3) and extended (9.0) windows (t=1.41, p=0.16). As expected, there was a striking difference seen in patients receiving IV thrombolysis between early (54.5%) and extended (4.5%) windows (χ²=48.48, p<0.001). Post‐operative hematoma also was not different between the early (23.8%) and extended (14.9%) windows (χ² = 0.69, p‐value = 0.40). Symptomatic intracerebral hemorrhage (SICH) was only seen in 3.4% of patient in the early window and 2.9% of patients in extended window. No significant difference was found in the mRS at discharge (early: 3.1, extended: 3.4, t=‐0.90, p=0.37) or at 90 days (early: 3.1, extended: 3.5, t=‐1.08, p=0.29). Additionally, in our multivariable logistic regression model, receiving EVT in the extended window didn't significantly affect the discharge mRS (β=0.10, p=0.27) or the 90 day mRS (β=‐0.15, p=0.38). In this model, increasing age, lower ASPECTS score, and higher admission NIHSS predicted a higher discharge mRS, while IV thrombolysis was linked to a lower discharge mRS. Higher admission NIHSS was associated with a higher mRS at both discharge and 90 days. Conclusion In our study, outcome of EVT in the extended time window in patients with DVO was comparable to EVT outcome in early window, with no increased hemorrhagic complications. More studies are required to further understand the risks and benefits of EVT in patients with DVO stroke

The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6. A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting. The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well. This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.

ObjectiveThe effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability.MethodsAccording to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up.ResultsIn total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2–4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28–2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58–0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17–3.55) and lower mortality (RR 0.72; 95% CI 0.62–0.84) compared with unsuccessful reperfusion.ConclusionsAcute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/.

In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines-Stroke clinical registry. We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines-Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3-7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%-38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.

Background: Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. While most guidelines lifted the age restriction, few patients enrolled in clinical trials were over 79 years of age. We studied EVT over time in San Diego County as it relates to patient age. We sought to understand age distribution of patients receiving EVT, frequency by which patients 79 and older received treatment, and whether that frequency changed over time. Methods: We included AIS patients with a reported age and NIHSS from 10 EVT capable centers from July 2016 through December 2018 from the San Diego County EMS Stroke Registry. We analyzed frequency of EVT by patient age, last known normal (LKN) to groin puncture time, NIHSS and hospital discharge disposition. Results: Between July 2016 and December 2018, of 7,049 AIS patients, 659 (9.3%) received EVT. The mean (±SD) age of EVT patients was 71.9 (±15.6) years, ranging from 24 to 104 years old. Of these patients, 250 (37.9%) were &gt;79 years. On average (±SD), 22.1 (±4.2) patients received EVT per month. Rate of EVT use among all AIS patients did not change over time (p=.24). On average (±SD) 8.4 (±3.3) patients &gt;79 years underwent EVT per month. Rate of EVT among patients &gt;79 years did not change over time (p=.31). EVT rate among patients ≤ 79 years increased over time (p=.02). EVT patients &gt;79 years had a mean (±SD) initial NIHSS of 19.2 (±8.2) compared to EVT patients ≤ 79 years NIHSS 16.0 (±8.6) (p=.000002). Overall mean (±SD) LKN to groin puncture was 6.2 hours (±7.0), &gt;79 years 5.6 (±5.7), ≤ 79 years 6.5 hours (±7.6) (p=.11). EVT patients &gt;79 years were discharged to a Skilled Nursing Facility (SNF) (32.9%), died in-hospital (19.0%), and transferred to acute care (15.9%); patients ≤ 79 years were discharged to home (35.2%), SNF (17.6%), and Inpatient Rehabilitation Facility (15.7%). Conclusion: Endovascular thrombectomy for patients older than 79 years accounts for nearly one in four patients receiving EVT. The frequency of EVT use in the elderly did not change over time while use in patients under age 80 increased slightly. However, overall use of EVT remained consistent. Older patients receiving EVT had a higher NIHSS and were more commonly discharged to a SNF compared to younger patients.

Acute ischemic stroke (AIS) affects approximately 11.9 million people annually, with large vessel occlusion (LVO) accounting for 10-20% of cases. While endovascular thrombectomy (EVT) is established for AIS with LVO, recent trials have expanded treatment to patients with Alberta Stroke Program Early CT Score (ASPECTS) 3-5. However, the efficacy and safety of EVT in patients with ASPECTS ≤2, representing extremely large infarcts with poor prognoses, remain uncertain due to limited evidence. This study evaluates EVT outcomes in this high-risk population. PubMed, Embase, and Web of Science were searched (January 1, 2010-September 20, 2024) for studies comparing EVT plus best medical treatment (BMT) versus BMT alone in AIS patients with ASPECTS ≤2. Outcomes included favorable functional outcome (FFO, mRS 0-2), moderate functional outcome (MFO, mRS 0-3), modified Rankin Scale (mRS) shift, symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), and 90-day mortality. Unadjusted odds ratios (ORs) and risk differences (RDs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed with the I² statistic. Seven studies involving 718 patients (305 EVT, 413 BMT) were included. EVT significantly improved FFO (11.8% vs. 1.6%; OR 5.39, 95% CI 2.06-14.13, P=0.0002), MFO (24.2% vs. 11.5%; OR 2.50, 95% CI 1.53-4.09, P=0.0003), and mRS shift (OR 1.64, 95% CI 1.30-2.06, P<0.001). However, EVT increased sICH (16.5% vs. 2.4%; OR 5.30, 95% CI 1.03-27.39, P<0.001) and any ICH (40.7% vs. 14.9%; OR 3.91, 95% CI 2.24-6.83, P<0.001). No significant difference in 90-day mortality was observed (45.5% vs. 50.8%; OR 0.72, 95% CI 0.34-1.53, P=0.40), though EVT showed a trend toward reduced mortality. EVT significantly improves functional outcomes in AIS patients with ASPECTS ≤2; however, the absolute benefits remain modest, given the poor prognosis associated with large infarcts. While EVT increases hemorrhagic complications, it does not increase mortality and may provide meaningful benefits for carefully selected patients. Further large-scale trials are needed to refine EVT guidelines.

Background: Endovascular thrombectomy (EVT) efficacy and safety is not established in patients with large core. We evaluated the clinical and radiologic outcomes following EVT in acute strokes with large ischemic core lesions defined by CT ASPECTS and/or CTP. Methods: From a multicenter prospective cohort study of imaging selection for thrombectomy (SELECT), patients with large ischemic core on CTP (rCBF&lt; 30%) &gt;50 ml and/or ASPECT≤5 up to 24 hrs from last known well were identified at 9 U.S centers. All patients received a baseline CT and CTP with automated ischemic core determination by RAPID. A blinded core lab adjudicated all images. The primary outcome was 90 day mRS 0-2. Safety outcomes were sICH and mortality. Outcomes of EVT patients were compared to those who received medical management (MM) only. Results: Of 445 enrolled, 106 had large core on either CT or CTP: 71 ASPECTS≤5 (EVT 37, MM 34) and 75 CTP core &gt;50 ml (EVT 40, MM 35), 40 on both CT and CTP. Median (IQR) age 66 yr, NIHSS 20 (16-23), time to puncture 224 min (range 69-832), ASPECTS 5 (4-6) and CTP core 72 ml (41-96). Baseline characteristics were similar in EVT vs. MM patients in both CT and CTP definition groups. The EVT group had better mRS 0-2 rates as compared to MM (32 % vs 14%), aOR: 2.9 (95% CI: 1.0-7.9, p=0.041) and a favorable mRS shift on ordinal analysis aOR: 2.0 (95% CI 1.0-4.1, p=0.049), smaller final infarct volume 96 (49-196) vs 175 (127-225) ml, p=0.02, and less infarct growth 44 (0.7-107.6) vs 83 (61-133) ml, p=0.03 with similar mortality 29% EVT, 42% MM, p=0.16 and sICH 13% EVT, 7% MM, p=0.3. EVT patients were more likely to achieve mRS 0-2 if treated early (0-6) vs late (&gt;6-24 hrs) for both CTP defined (27% vs 0%) and CT defined large core (44% vs. 18%). The good outcome declined by 20% for each hr of treatment delay (Fig 1). Conclusion: EVT may be effective and safe for patients with a large core, especially if treated early. RCTs are needed.

Background: While endovascular thrombectomy (EVT) patients may not achieve functional independence, they may avoid devastating outcomes as in profound disability/death. Methods: DEFUSE 3 patients who did not achieve mRS 0-2 were assessed for a shift towards reductions in severe (mRS 4-6) and profound (mRS 5-6) disability, mortality, length of stay (LOS) and increased rates of home/rehabilitation discharges. Results: 126 of the 182 randomized in DEFUSE 3 did not achieve mRS 0-2 (EVT 51, MM 75). Baseline characteristics were similar. EVT was associated with a higher mRS 3 rate (28% vs 18%) and lower rates of severe (72% vs 82%) and profound disability (39% vs. 50%), EVT vs MM respectively, with a trend for a shift towards less disability aOR=1.6 (95%CI=0.9-3.2, P=0.138), figure 1. Mortality rates were numerically lower with EVT (25% vs 31, p=0.528). EVT patients had a trend for shorter LOS (8.6 (6.5-13.7) vs 9.3 (7.1-16.3) days, p=0.156) and increased rates of home/rehabilitation discharges 51% vs. 40%, p=0.224. Older age correlated independently with severe disability aOR=1.04 per year/age, (95%CI=1.01-1.07, p=0.023) as did more severe strokes, aOR per NIHSS point=1.07, 95%CI=0.99-1.15, P=0.096). Larger final infarct volumes had a trend towards severe disability in EVT aOR=1.005, 95%CI=0.996-1.013, p=0.257, but not in MM aOR=1.0 (95% CI 0.993-1.007, p=0.966). Lack of reperfusion (&gt;90% Tmax&gt;6 reduction) had a strong trend for severe disability in MM (83% in non-reperfusers vs. 50% for reperfusers), p=0.056, but not in EVT: 77% vs. 63%, p=0.484. Conclusion: In patients who did not achieve functional independence, EVT resulted in reduced rates of severe and profound disability, decreased length of stay and increased home and rehabilitation discharges. Older patients, more severe strokes and those who did not achieve reperfusion were more likely to have severe disability especially if not treated with EVT. EVT may result in avoiding severe disability in elderly patients.

Background: Most trials for the endovascular thrombectomy (EVT) of large vessel ischemic stroke excluded patients with large core infarcts and low Alberta Stroke Program Early CT Score (ASPECTS). As a result, the current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of EVT for patients with an ASPECTS of 6 or more. However recent data from the HERMES collaboration has shown that even stroke patients with large core infarcts may still benefit from EVT. Objectives: Through this systematic review, we aim to determine the safety and efficacy of EVT for large vessel ischemic stroke patients with low ASPECTS (5 or less). Methods: Medline, Cochrane Central Register of Systematic Reviews and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS acute ischemic stroke patients. Patients with low ASPECTS who underwent EVT were compared to those who only received best medical therapy (BMT). A meta-analysis of proportions was done to compare the outcomes of the two groups in terms of symptomatic intracranial hemorrhage, mortality and good 3-month functional outcomes (modified Rankin Scale &lt; 2). Results: Nine studies with a total of 1,196 acutes stroke patients with low ASPECTS (712 undergoing EVT and 484 with only BMT) were included in the study. There was a trend towards a higher rate of sICH in the EVT group (9.2%; 95% CI 6.1% to 13.6%; I 2 53.37%) compared to the BMT group (5.5%; 95% CI 3.7% to 8.1%; I 2 =0%) but this did not reach statistical significance (p=0.11). There was no difference (p=0.41) in the pooled 3-month mortality of EVT patients (30.7%; 95% CI 21.7 to 41.5%; I 2 84.23%) and BMT patients (36.6%; 95% CI 26.4% to 48.1%; I 2 76.2%). Patients who underwent EVT had significantly better (p=0.001) 3-month outcomes, with 27.7% (95% 21.8 to 34.5%; I 2 62.08%) of patients attaining an MRS 0-2 compared to only 3.7% (95% 2.3 to 5.9%; I 2 87.21%) of patients in the BMT. Conclusion: Our meta-analysis suggests that acute stroke patients with low ASPECTS score may still benefit from EVT. Larger registry based studies and randomized controlled trials are needed to further substantiate the findings of our review.

Background and Purpose: Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). Randomized trials of posterior circulation large vessel occlusion (PC-LVO) patients have failed to show a benefit of EVT over medical therapy (MEDT). We performed a systematic review and meta-analysis to understand better whether EVT is beneficial for PC-LVO. Methods: Using the Nested Knowledge AutoLit living review platform, we identified randomized control trials and prospective studies that reported functional outcomes in patients with PC-LVO treated with EVT versus MEDT. The primary outcome variable was 90-day modified Rankin Scale (mRS) 0-3, and secondary outcome variables included 90-day mRS 0-2, 90-day mortality, and rate of symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure to calculate pooled odds ratios. Results: Three studies with 1,248 patients, 860 in the EVT arm and 388 in the MEDT arm, were included in the meta-analysis. The favorable outcome rate (mRS 0-3) in EVT patients was 39.9% (95% CI: 30.6-50.1%) versus 24.5% in MEDT patients (95% CI: 9.6-49.8%). EVT patients had higher mRS 0-2 rates (31.8% [95% CI: 25.7-38.5%] versus 19.7% [95% CI: 7.4-42.7%]) and lower mortality (42.1% [95% CI: 35.9-48.6%] versus 52.8% [95% CI: 33.3-71.5%]) compared to MEDT patients, but neither result was statistically significant. EVT patients were more likely to develop sICH (OR=10.36; 95% CI: 3.92-27.40). Conclusions: EVT treatment of PC-LVO trended toward superior functional outcomes and reduced mortality compared to MEDT despite a trend toward increased sICH in EVT patients. Existing randomized and prospective studies are insufficiently powered to demonstrate a benefit of EVT over MEDT in PC-LVO patients.

Background: It is unclear what factors clinicians consider when deciding about endovascular thrombectomy (EVT) in acute ischemic stroke patients with a pre-existing disability. We aimed to explore international practice patterns and preferences for EVT in patients with a pre-stroke disability, defined as a modified Rankin score (mRS) ≥ 2.Methods: Electronic survey link was sent to principal investigators of five major EVT trials and members of a professional interventional neurology society.Results: Of the 81 survey-responding clinicians, 57% were neuro-interventionalists and 33% were non-interventional stroke clinicians. Overall, 64.2% would never or almost never consider EVT for a patient with pre-stroke mRS of 4-5, and 49.3% would always or almost always offer EVT for a patient with pre-stroke mRS 2-3. Perceived benefit of EVT (89%) and severity of baseline disability (83.5%) were identified as the most important clinician-level and patient-level factors that influence EVT decisions in these patients.Conclusion: In this survey of 80 respondents, we found that EVT practice for patients with pre-stroke disability across the world is heterogenous and depends upon patient characteristics. Individual clinician opinions substantially alter EVT decisions in pre-stroke disabled patients.