. 2023 Feb 14;100(7):e751-e763.

doi: 10.1212/WNL.0000000000201543. Epub 2022 Nov 4.

Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan

James E Siegler¹, Muhammad M Qureshi¹, Raul G Nogueira¹, Kanta Tanaka¹, Simon Nagel¹, Patrik Michel¹, Nicholas Vigilante¹, Marc Ribo¹, Hiroshi Yamagami¹, Shinichi Yoshimura¹, Mohamad Abdalkader¹, Diogo C Haussen¹, Mahmoud H Mohammaden¹, Stefania Nannoni¹, Markus A Möhlenbruch¹, Hilde Henon¹, Sunil A Sheth¹, Santiago Ortega-Gutierrez¹, Marta Olive-Gadea¹, Francois Caparros¹, Fatih Seker¹, Syed Zaidi¹, Alicia C Castonguay¹, Kazutaka Uchida¹, Nobuyuki Sakai¹, Ajit S Puri¹, Mudassir Farooqui¹, Kazunori Toyoda¹, Sergio Salazar-Marioni¹, Masataka Takeuchi¹, Behzad Farzin¹, Hesham E Masoud¹, Anna Luisa Kuhn¹, Ameena Rana¹, Masafumi Morimoto¹, Masunari Shibata¹, Tadashi Nonaka¹, Piers Klein¹, Anvitha Sathya¹, Nicole L Kiley¹, Charlotte Cordonnier¹, Davide Strambo¹, Jelle Demeestere¹, Peter A Ringleb¹, Daniel Roy¹, Osama O Zaidat¹, Tudor G Jovin¹, Johannes Kaesmacher¹, Urs Fischer¹, Jean Raymond¹, Thanh N Nguyen¹

Affiliations

Affiliation

¹ From the Cooper Neurological Institute (J.E.S., A.R., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Radiology (M.M.Q., M.A., P.K., A.S., N.L.K., T.N.N.), Boston Medical Center, Boston University School of Medicine, MA; Departments of Radiation Oncology (M.M.Q.) and Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (R.G.N.), University of Pittsburgh Medical Center, PA; Division of Stroke Care Unit (Kanta Tanaka, Kazunori Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology (S. Nagel), Klinikum Ludwigshafen; Departments of Neurology (S. Nagel, P.A.R.) and Neuroradiology (M.A.M., F.S.), Heidelberg University Hospital, Germany; Department of Neurology (P.M., D.S.), Lausanne University Hospital, University of Lausanne, Switzerland; Cooper Medical School of Rowan University (N.V.), Camden, NJ; Stroke Unit (M.R., M.O.-G.), Neurology, Hospital Vall D'Hebron, Barcelona, Spain; Department of Stroke Neurology (H.Y.), NHO Osaka National Hospital, Japan; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurology (D.C.H., M.H.M.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Clinical Neurosciences (S. Nannoni), University of Cambridge, United Kingdom; University of Lille (H.H., F.C., C.C.), Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, France; Department of Neurology (S.A.S., S.S.-M.), UTHealth McGovern Medical School, Houston, TX; Department of Neurology (S.O.G., M.F.), University of Iowa Hospitals and Clinics, Iowa City,; Department of Neurology (S.Z., A.C.), University of Toledo, OH; Department of Neurosurgery (K.U.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurovascular Research (N.S.), Kobe City Medical Center General Hospital, Japan; Division of Neurointerventional Radiology (A.S.P., A.L.K.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurosurgery (M.T.), Seisho Hospital, Odawara, Japan; Department of Radiology (B.F., D.R., J.R.), Centre Hospitalier de L'Université de Montréal, Canada; Department of Neurology (H.E.M.), State University of New York, Upstate Medical University, Syracuse, NY; Department of Neurosurgery (M. Morimoto), Yokohama Shintoshi Neurosurgical Hospital; Department of Neurology (M.S.), Ise Red Cross Hospital; Department of Neurosurgery (T.N.), Sapporo Shiroishi Memorial Hospital, Japan; Neurology Department (J.D.), Leuven University Hospital, Belgium; Department of Neurology (P.A.R.), Heidelberg University Hospital, Germany; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; Institute of Diagnostic and Interventional Neuroradiology (J.K.), University of Bern, Inselspital; Institute of Diagnostic (J.K.), Interventional and Pediatric Radiology, University Hospital Bern, Inselspital; Department of Neurology (U.F.), University Hospital Basel, University of Basel; and Department of Neurology (U.F.), University Hospital Bern, University of Bern, Switzerland.

PMID: 36332983
PMCID: PMC9969918
DOI: 10.1212/WNL.0000000000201543

Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan

James E Siegler et al. Neurology. 2023.

. 2023 Feb 14;100(7):e751-e763.

doi: 10.1212/WNL.0000000000201543. Epub 2022 Nov 4.

Authors

Affiliation

¹ From the Cooper Neurological Institute (J.E.S., A.R., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Radiology (M.M.Q., M.A., P.K., A.S., N.L.K., T.N.N.), Boston Medical Center, Boston University School of Medicine, MA; Departments of Radiation Oncology (M.M.Q.) and Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (R.G.N.), University of Pittsburgh Medical Center, PA; Division of Stroke Care Unit (Kanta Tanaka, Kazunori Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology (S. Nagel), Klinikum Ludwigshafen; Departments of Neurology (S. Nagel, P.A.R.) and Neuroradiology (M.A.M., F.S.), Heidelberg University Hospital, Germany; Department of Neurology (P.M., D.S.), Lausanne University Hospital, University of Lausanne, Switzerland; Cooper Medical School of Rowan University (N.V.), Camden, NJ; Stroke Unit (M.R., M.O.-G.), Neurology, Hospital Vall D'Hebron, Barcelona, Spain; Department of Stroke Neurology (H.Y.), NHO Osaka National Hospital, Japan; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurology (D.C.H., M.H.M.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Clinical Neurosciences (S. Nannoni), University of Cambridge, United Kingdom; University of Lille (H.H., F.C., C.C.), Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, France; Department of Neurology (S.A.S., S.S.-M.), UTHealth McGovern Medical School, Houston, TX; Department of Neurology (S.O.G., M.F.), University of Iowa Hospitals and Clinics, Iowa City,; Department of Neurology (S.Z., A.C.), University of Toledo, OH; Department of Neurosurgery (K.U.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurovascular Research (N.S.), Kobe City Medical Center General Hospital, Japan; Division of Neurointerventional Radiology (A.S.P., A.L.K.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurosurgery (M.T.), Seisho Hospital, Odawara, Japan; Department of Radiology (B.F., D.R., J.R.), Centre Hospitalier de L'Université de Montréal, Canada; Department of Neurology (H.E.M.), State University of New York, Upstate Medical University, Syracuse, NY; Department of Neurosurgery (M. Morimoto), Yokohama Shintoshi Neurosurgical Hospital; Department of Neurology (M.S.), Ise Red Cross Hospital; Department of Neurosurgery (T.N.), Sapporo Shiroishi Memorial Hospital, Japan; Neurology Department (J.D.), Leuven University Hospital, Belgium; Department of Neurology (P.A.R.), Heidelberg University Hospital, Germany; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; Institute of Diagnostic and Interventional Neuroradiology (J.K.), University of Bern, Inselspital; Institute of Diagnostic (J.K.), Interventional and Pediatric Radiology, University Hospital Bern, Inselspital; Department of Neurology (U.F.), University Hospital Basel, University of Basel; and Department of Neurology (U.F.), University Hospital Bern, University of Bern, Switzerland.

PMID: 36332983
PMCID: PMC9969918
DOI: 10.1212/WNL.0000000000201543

Abstract

Background and objectives: Current guidelines do not address recommendations for mechanical thrombectomy (MT) in the extended time window (>6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with preexisting modified Rankin Scale (mRS) > 1. In this study, we evaluated the outcomes of MT vs medical management in patients with prestroke disability presenting in the 6- to 24-hour time window with acute LVO.

Methods: We analyzed a multinational cohort (61 sites, 6 countries from 2014 to 2020) of patients with prestroke (or baseline) mRS 2 to 4 and anterior circulation LVO treated 6-24 hours from TLSW. Patients treated in the extended time window with MT vs medical management were compared using multivariable logistic regression and inverse probability of treatment weighting (IPTW). The primary outcome was the return of Rankin (ROR, return to prestroke mRS by 90 days).

Results: Of 554 included patients (448 who underwent MT), the median age was 82 years (interquartile range [IQR] 72-87) and the National Institutes of Health Stroke Scale (NIHSS) was 18 (IQR 13-22). In both MV logistic regression and IPTW analysis, MT was associated with higher odds of ROR (adjusted OR [aOR] 3.96, 95% CI 1.78-8.79 and OR 3.10, 95% CI 1.20-7.98, respectively). Among other factors, premorbid mRS 4 was associated with higher odds of ROR (aOR, 3.68, 95% CI 1.97-6.87), while increasing NIHSS (aOR 0.90, 95% CI 0.86-0.94) and decreasing Alberta Stroke Program Early Computed Tomography Scale score (aOR per point 0.86, 95% CI 0.75-0.99) were associated with lower odds of ROR. Age, intravenous thrombolysis, and occlusion location were not associated with ROR.

Discussion: In patients with preexisting disability presenting in the 6- to 24-hour time window, MT is associated with a higher probability of returning to baseline function compared with medical management.

Classification of evidence: This investigation's results provide Class III evidence that in patients with preexisting disability presenting 6-24 hours from the TLSW and acute anterior LVO stroke, there may be a benefit of MT over medical management in returning to baseline function.

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Figures

**Figure. Flow Diagram of Patient Selection**

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Comment in

Reader Response: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.
Bruno A, Nichols FT. Bruno A, et al. Neurology. 2023 Mar 28;100(13):641-642. doi: 10.1212/WNL.0000000000207197. Neurology. 2023. PMID: 36973069 Free PMC article. No abstract available.
Author Response: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.
Siegler JE, Nagel S, Nguyen TN. Siegler JE, et al. Neurology. 2023 Mar 28;100(13):642. doi: 10.1212/WNL.0000000000207198. Neurology. 2023. PMID: 36973071 Free PMC article. No abstract available.

References

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Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan

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Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan

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