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. 2025 Nov 10:15910199251347782.
doi: 10.1177/15910199251347782. Online ahead of print.

Endovascular treatment vs. best medical management for late window ischemic stroke patients with large vessel occlusion

Charlotte Zerna  1   2 , Johann Ospel  1 , Emma Harrison  3 , Timothy J Kleinig  4 , Volker Puetz  5 , Daniel Po Kaiser  6 , Brett Graham  7 , Amy Yx Yu  8 , Brian van Adel  9 , Jai J Shankar  10 , Ryan A McTaggart  11 , Vitor Pereira  11 , Donald F Frei  12 , Mayank Goyal  1 , Michael D Hill  1
Affiliations

Endovascular treatment vs. best medical management for late window ischemic stroke patients with large vessel occlusion

Charlotte Zerna et al. Interv Neuroradiol. .

Abstract

BackgroundTo compare the benefit of endovascular treatment(EVT) in acute ischemic stroke(AIS) patients with large vessel occlusion(LVO) presenting > 6 h from last known well outside a clinical trial setting to best medical management and to EVT in a randomized trial setting.MethodsData from a retrospective multicenter cohort study (ESCAPE-LATE) of AIS-LVO patients treated with EVT beyond 6 hours from last known well at former ESCAPE trial sites were pooled with historical data from ESCAPE trial late time window patients. Unadjusted and adjusted 90-day modified Rankin Scale (mRS) score was compared between ESCAPE-LATE patients, ESCAPE late time window EVT arm and control arm patients.ResultsA total of 249 patients were included in the analysis: 200 ESCAPE-LATE patients (for 141 of whom 90-day clinical outcomes were available) and 49 ESCAPE patients, for all of whom clinical outcome data were available (control arm: 20 and EVT arm: 29). Good clinical outcome (mRS 0-2 at 90 days) was nominally, albeit not significantly, lower in patients not treated with EVT (5/19[26.3%]) as compared to ESCAPE EVT arm patients (13/29[44.8%] and ESCAPE-LATE patients (66/141[46.8%]). After adjustment, a graded mRS pattern was seen, whereby patients treated with EVT did better as compared to non-treated patients, and those who underwent EVT in the ESCAPE trial had better mRS as compared to those included in ESCAPE-LATE who underwent EVT in clinical routine.ConclusionPatients presenting beyond 6 hours from last known well who are treated with EVT in a real-world setting show comparable benefit to patients treated in a clinical trial setting.

Keywords: Stroke; ischemia; large vessel occlusion; late time window; mechanical thrombectomy.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DFF reports personal fees from Penumbra, Stryker, Genentech, and Siemens, outside the submitted work. DG is an officer of NoNO and is the inventor of three patents, owned by NoNO. MG reports personal fees from Medtronic, Stryker, Microvention, and Mentice, during the conduct of the study; unrestricted research grants to University of Calgary from NoNO, Stryker, and Medtronic; patents for a system of acute stroke diagnosis, with loyalties paid to GE Healthcare, and a system of simulation for acute neurointervention, with royalties paid to Mentice; and ownership interest in Circle Neurovascular. MDH reports grants from Canadian Institutes for Health Research, Alberta Innovates, and NoNO, for the conduct of the study; reports personal fees from Merck; reports non-financial support from Hoffmann-La Roche Canada; reports grants from Covidien (Medtronic), Boehringer-Ingleheim, Stryker, and Medtronic, outside the submitted work; reports a patent for systems and methods for assisting in decision-making and triaging for acute stroke patients, issued to US Patent office Number 62/086,077; owns stock in Calgary Scientific; is a director of the Canadian Federation of Neurological Sciences and Circle NeuroVascular; and has received grant support from Alberta Innovates Health Solutions, CIHR, Heart & Stroke Foundation of Canada, and the National Institutes of Neurological Disorders and Stroke. All other authors declare no competing interests.

Figures

Figure 1.
Figure 1.
Flowchart of included and excluded patients.
Figure 2.
Figure 2.
Unadjusted (a) and adjusted (b) 90-day modified Rankin Scale (mRS) score 0-6 of ESCAPE LATE patients, late time window ESCAPE EVT arm patients and late window ESCAPE control arm patients. mRS categories are shown in ascending order from left to right. Numbers in the bar charts indicate the percentage of patients in each mRS category. Adjusted probabilities for each mRS category in (b) were obtained from a multivariable ordinal logistic regression model with patient age, sex, NIHSS, baseline ASPECTS and occlusion location as adjustment variables, clustered by study group. Note that 3-months mRS data was available for 141/200 ESCAPE-LATE patients.
Figure 3.
Figure 3.
Unadjusted (a) and adjusted (b) 90-day modified rankin score (mRS) 0-6 of ESCAPE LATE patients who underwent no advanced imaging vs. CT perfusion vs. MR perfusion. mRS categories are shown in ascending order from left to right. Numbers in the bar charts indicate the percentage of patients in each mRS category. Adjusted probabilities for each mRS category in (b) were obtained from a multivariable ordinal logistic regression model with patient age, sex, NIHSS, baseline ASPECTS and occlusion location as adjustment variables, clustered by study group. Note that 3-months mRS data was available for 141/200 ESCAPE-LATE patients.
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