Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

doi:10.5853/jos.2023.04259

. 2024 May;26(2):269-279.

doi: 10.5853/jos.2023.04259. Epub 2024 May 30.

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

Kanta Tanaka^{1

2}, Hiroshi Yamagami³, Muhammad M Qureshi⁴, Kazutaka Uchida⁵, James E Siegler⁶, Raul G Nogueira⁷, Shinichi Yoshimura⁵, Nobuyuki Sakai⁸, Nicolas Martinez-Majander⁹, Simon Nagel^{10

11}, Jelle Demeestere¹², Volker Puetz^{13

14}, Diogo C Haussen¹⁵, Mohamad Abdalkader¹⁶, Marta Olive-Gadea¹⁷, Mahmoud H Mohammaden¹⁵, João Pedro Marto¹⁸, Anne Dusart¹⁹, Simon Winzer¹³, Liisa Tomppo⁹, Francois Caparros²⁰, Hilde Henon²⁰, Flavio Bellante¹⁹, João Nuno Ramos²¹, Santiago Ortega-Gutierrez²², Sunil A Sheth²³, Stefania Nannoni²⁴, Johannes Kaesmacher²⁵, Lieselotte Vandewalle¹², Sergio Salazar-Marioni²³, Mudassir Farooqui²², Pekka Virtanen²⁶, Rita Ventura¹⁸, Syed Zaidi²⁷, Alicia C Castonguay²⁷, Ajit S Puri²⁸, Behzad Farzin²⁹, Hesham E Masoud³⁰, Piers Klein¹⁶, Jessica Jesser³¹, Manuel Requena¹⁷, Tomas Dobrocky²⁵, Daniel P O Kaiser³², Erno Peltola²⁶, Davide Strambo³³, Markus A Möhlenbruch³⁴, Eugene Lin³⁵, Peter A Ringleb¹¹, Osama O Zaidat³⁵, Charlotte Cordonnier²⁰, Daniel Roy²⁹, Robin Lemmens¹², Marc Ribo¹⁷, Daniel Strbian⁹, Urs Fischer^{36

37}, Patrik Michel³³, Jean Raymond²⁹, Thanh N Nguyen^{16

38}

Affiliations

¹ Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.
² Stroke Center, Kindai University Hospital, Osakasayama, Japan.
³ Division of Stroke Prevention and Treatment, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
⁴ Department of Radiology, Radiation Oncology, Boston Medical Center, Boston, MA, USA.
⁵ Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
⁶ Department of Neurology, University of Chicago, Chicago, IL, USA.
⁷ Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
⁸ Department of Neurosurgery, Kobe City Medical General Hospital, Kobe, Japan.
⁹ Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
¹⁰ Department of Neurology, Klinikum Ludwigshafen, Heidelberg University Hospital, Ludwigshafen, Germany.
¹¹ Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
¹² Department of Neurology, Leuven University Hospital, Leuven, Belgium.
¹³ Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁴ Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁵ Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA.
¹⁶ Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
¹⁷ Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
¹⁸ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
¹⁹ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
²⁰ Department of Neurology, Centre Hospitalier Universitaire de Lille, University of Lille, Lille, France.
²¹ Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²² Department of Neurology, University of Iowa, Iowa City, IA, USA.
²³ Department of Neurology, UTHealth Houston, Houston, TX, USA.
²⁴ Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
²⁵ Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland.
²⁶ Department of Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
²⁷ Department of Neurology, University of Toledo, Toledo, OH, USA.
²⁸ Division of Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA.
²⁹ Department of Radiology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada.
³⁰ Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA.
³¹ Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany.
³² Department of Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
³³ Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland.
³⁴ Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.
³⁵ Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA.
³⁶ Department of Neurology, University Hospital Basel, Switzerland.
³⁷ Department of Neurology, University Hospital Bern, Switzerland.
³⁸ Department of Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.

PMID: 38836274
PMCID: PMC11164586
DOI: 10.5853/jos.2023.04259

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

Kanta Tanaka et al. J Stroke. 2024 May.

. 2024 May;26(2):269-279.

doi: 10.5853/jos.2023.04259. Epub 2024 May 30.

Authors

Affiliations

¹ Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.
² Stroke Center, Kindai University Hospital, Osakasayama, Japan.
³ Division of Stroke Prevention and Treatment, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
⁴ Department of Radiology, Radiation Oncology, Boston Medical Center, Boston, MA, USA.
⁵ Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
⁶ Department of Neurology, University of Chicago, Chicago, IL, USA.
⁷ Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
⁸ Department of Neurosurgery, Kobe City Medical General Hospital, Kobe, Japan.
⁹ Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
¹⁰ Department of Neurology, Klinikum Ludwigshafen, Heidelberg University Hospital, Ludwigshafen, Germany.
¹¹ Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
¹² Department of Neurology, Leuven University Hospital, Leuven, Belgium.
¹³ Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁴ Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁵ Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA.
¹⁶ Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
¹⁷ Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
¹⁸ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
¹⁹ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
²⁰ Department of Neurology, Centre Hospitalier Universitaire de Lille, University of Lille, Lille, France.
²¹ Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
²² Department of Neurology, University of Iowa, Iowa City, IA, USA.
²³ Department of Neurology, UTHealth Houston, Houston, TX, USA.
²⁴ Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
²⁵ Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland.
²⁶ Department of Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
²⁷ Department of Neurology, University of Toledo, Toledo, OH, USA.
²⁸ Division of Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA.
²⁹ Department of Radiology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada.
³⁰ Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA.
³¹ Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany.
³² Department of Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
³³ Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland.
³⁴ Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.
³⁵ Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA.
³⁶ Department of Neurology, University Hospital Basel, Switzerland.
³⁷ Department of Neurology, University Hospital Bern, Switzerland.
³⁸ Department of Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.

PMID: 38836274
PMCID: PMC11164586
DOI: 10.5853/jos.2023.04259

Abstract

Background and purpose: We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability.

Methods: In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1).

Results: A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995).

Conclusion: A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

Keywords: Activities of daily living; Endovascular therapy; Ischemic stroke; Outcome; Reperfusion.

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Conflict of interest statement

Conflicts of interest

H. Yamagami received research grants from Bristol-Myers Squibb; lecturer fees from Stryker, Medtronic, Johnson & Johnson, Bayer, Daiichi Sankyo, Bristol-Myers Squibb, and Otuska Pharmaceutical; and is an advisory board for Daiichi Sankyo. Siegler reported consultancy fees from Ceribell and involvement in the AstraZeneca Speakers Bureau. Nogueira reported consultancy fees from Biogen, Brainomix, Corindus, Cerenovus, Stryker, Medtronic, Ceretrieve, Anaconda, Biomed, Vesalio, Imperative Care, NeuroVasc Technologies, Viz AI, Genentech, Prolong Pharmaceuticals, Perfuze, Phenox, RapidPulse, and stock options in Viz AI, Vesalio, Perfuze, Corindus, Brainomix, and Ceretrieve, grants from Cerenovus and Stryker. S. Yoshimura reported research grants from Stryker, Siemens Healthineers, Bristol-Myers Squibb, Sanofi, Eisai, Daiichi Sankyo, Teijin Pharma, Chugai Pharmaceutical, HEALIOS, Asahi Kasei Medical, Kowa, CSL Behring and lecturer fees from Stryker, Medtronic, Johnson & Johnson, Kaneka, Terumo, Biomedical Solutions, Boehringer-Ingelheim, Daiichi Sankyo, Bayer and Bristol-Meyers Squibb. N. Sakai received a research grant from Biomedical Solutions, Medtronic, Terumo, and TG Medical; lecturer fees from Asahi-Intec, Biomedical Solutions, Daiichi-Sankyo, Kaneka, Medtronic, and Terumo; and is a member of the advisory boards for Johnson & Johnson, Medtronic, and Terumo. S. Nagel reported consultancy fees from Brainomix and is a speaker with Boehringer Ingelheim and Pfizer. V. Puetz reported lecturer fees from Daiichi Sankyo. Haussen reported consultancy fees from Vesalio, Cerenovus, Stryker, Brainomix, Poseydon Medical, and Chiesi, USA; DSMB from the Jacobs Institute; and stock options in Viz AI. J. P. Marto reported consultancy feed from Amicus Therapeutics and Boehringer Ingelheim and is a Speaker with Boehringer Ingelheim. Sheth reported consultancy fees from Imperative Care, Viz AI, Penumbra, compensation from Motif Neurosciences, and grants from the National Institutes of Health. J. Kaesmacher reported grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern. D. P. O. Kaiser reported grants from the Joachim Herz Foundation. M. A. Möhlenbruch reported grants from Medtronic, Stryker, and MicroVention. P. A. Ringleb reported travel support from Bayer and Bristol Myers Squibb, and a consultancy for Daiichi Sankyo Company, and Boehringer Ingelheim. M. Ribo reported consultancy fees from Medtronic, MiniMed, Cerenovus, AptaTargets, Stryker, Philips and stock holdings in Methinks, Nora, and Anaconda Biomed. P. Michel reported grants from the University of Lausanne and Swiss National Science Foundation (SNF). T. N. Nguyen disclosed research support from Medtronic to her institution; is a member of the advisory board for Idorsia, Brainomix; and is an Associate Editor of Stroke.

Figures

**Figure 1.**
Flow diagram of patient selection. CLEAR, CT for Late Endovascular Reperfusion; NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; ASPECTS, Alberta Stroke Program Early CT Score.

**Figure 2.**
Distribution of modified Rankin Scale (mRS) at 90 days according to the pre-stroke mRS.

**Figure 3.**
The rate of primary outcome of functional independence or return of Rankin by reperfusion status with and without pre-stroke disability. mRS, modified Rankin Scale; eTICI, expanded Thrombolysis In Cerebral Infarction.

See this image and copyright information in PMC

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References

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1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418. - PubMed
1. Ganesh A, Luengo-Fernandez R, Pendlebury ST, Rothwell PM. Long-term consequences of worsened poststroke status in patients with premorbid disability. Stroke. 2018;49:2430–2436. - PMC - PubMed
1. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. - PubMed
1. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. - PubMed

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[1] Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, et al. Guidelines for mechanical thrombectomy in Japan, the fourth edition, March 2020: a guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021;61:163–192. - PMC - PubMed

[2] Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, et al. Guidelines for mechanical thrombectomy in Japan, the fourth edition, March 2020: a guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021;61:163–192. - PMC - PubMed

[3] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418. - PubMed

[4] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418. - PubMed

[5] Ganesh A, Luengo-Fernandez R, Pendlebury ST, Rothwell PM. Long-term consequences of worsened poststroke status in patients with premorbid disability. Stroke. 2018;49:2430–2436. - PMC - PubMed

[6] Ganesh A, Luengo-Fernandez R, Pendlebury ST, Rothwell PM. Long-term consequences of worsened poststroke status in patients with premorbid disability. Stroke. 2018;49:2430–2436. - PMC - PubMed

[7] Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. - PubMed

[8] Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. - PubMed

[9] Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. - PubMed

[10] Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21. - PubMed

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Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

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Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

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Abstract

Conflict of interest statement

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Abstract

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