Department of Radiology, Mayo Clinic Rochester, Rochester, MN, USA.
Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
J Neurol. 2024 May;271(5):2230-2237. doi: 10.1007/s00415-024-12198-3. Epub 2024 Feb 3.
Endovascular therapy (EVT) has been proven beneficial for treating acute ischemic strokes (AIS) with large vessel occlusion (LVO). Recent trials of DAWN and DEFUSE-3 have extended the treatment window to 6-24 h, sparking investigations into EVT outcomes for patients not eligible for DAWN/DEFUSE-3 criteria.
To assess the outcomes of endovascular therapy (EVT) for late-window anterior circulation large vessel occlusion (LVO) in acute ischemic stroke patients, comparing DAWN/DEFUSE-3 eligible (DD) and ineligible (NDND) groups.
This systematic review and meta-analysis examined EVT outcomes for patients with late-window anterior circulation LVO beyond 6 h. We categorized patients as DAWN/DEFUSE-3 eligible (DD) and ineligible (NDND). Our search covered PubMed, Embase, Web of Science, and Scopus. A total of 464 records were initially identified. After duplicate removal, 298 studies were screened. Nine studies were included and analyzed. Our analysis focused on study characteristics, baseline comparisons, risk of bias, and outcomes.
Baseline characteristics showed comparable age, gender, most comorbidities, NIHSS score, and ASPECTS between DAWN/DEFUSE-3 eligible (DD) and ineligible (NDND) patients. NDND patients' history showed a higher rate of atrial fibrillation and larger infarct volumes on baseline imaging. Successful reperfusion rates (TICI 2b-3) were similar between DD and NDND with 354 out of 469 in the DD group and 364 out of 459 in the NDND group (OR = 0.86; 95% CI 0.40, 1.84; p = 0.689), though with significant heterogeneity (I = 73%; P = 0.002). The proportion of patients with distal occlusions was significantly higher in the NDND group as compared to the DD group (137 (39.4%) of 347 patients versus 47 (11%) of 428 patients, respectively), with significant heterogeneity across studies (I = 85%, p = 0.023). Functional independence at 90 days (mRS 0-2) showed no significant difference between groups with 259 out of 802 in the DD group and 197 out of 668 in the NDND group (OR = 1.12; 95% CI 0.77, 1.63; p = 0.552) but also exhibited notable heterogeneity (I = 46%, p = 0.063). Symptomatic intracranial hemorrhage (sICH) rates were lower in DD with 14 out of 309 in the DD group and 47 out of 400 in NDND group (OR = 0.49; 95% CI 0.25, 0.93; p = 0.029) as compared to the NDND patients, showing no heterogeneity (I = 0%, p = 0.552). 90-day mortality was lower in DD with 43 out of 304 in the DD group and 107 out of 399 in the NDND group (OR = 0.55; 95% CI 0.37, 0.82; p = 0.004) as compared to NDND patients, with no significant heterogeneity (I = 0%, p = 0.536).
This meta-analysis demonstrates equivalent rates of functional independence between DD and NDND patients. However, the high proportion of distal occlusions and higher rates of sICH and mortality in NDND patients suggest caution in offering mechanical thrombectomy to DAWN/DEFUSE-3 ineligible patients. A more flexible approach to EVT eligibility criteria could benefit select patients in real-world practice. Nonetheless, further research is needed to identify which patients would benefit from expanded EVT eligibility criteria.
血管内治疗（EVT）已被证明对治疗大血管闭塞（LVO）的急性缺血性脑卒中（AIS）有益。最近的 DAWN 和 DEFUSE-3 试验将治疗时间窗延长至 6-24 小时，引发了对不符合 DAWN/DEFUSE-3 标准的患者进行 EVT 治疗的结果的研究。
评估晚期前循环大血管闭塞（LVO）急性缺血性脑卒中患者血管内治疗（EVT）的结果，比较 DAWN/DEFUSE-3 符合（DD）和不符合（NDND）标准的患者。
本系统评价和荟萃分析检查了超过 6 小时的晚期前循环 LVO 患者的 EVT 结果。我们将患者分为 DAWN/DEFUSE-3 符合（DD）和不符合（NDND）组。我们的检索涵盖了 PubMed、Embase、Web of Science 和 Scopus。最初共确定了 464 条记录。重复记录去除后，筛选了 298 项研究。纳入了 9 项研究进行分析。我们的分析重点是研究特征、基线比较、偏倚风险和结果。
基线特征显示，DAWN/DEFUSE-3 符合（DD）和不符合（NDND）患者的年龄、性别、大多数合并症、NIHSS 评分和 ASPECTS 相似。NDND 患者的病史显示，基线影像学上房颤发生率更高，梗死体积更大。在 DD 组中，354 例中有 354 例（86%）和 NDND 组中 364 例中有 364 例（459 例）（OR=0.86；95%CI 0.40，1.84；p=0.689）达到成功再灌注率（TICI 2b-3），尽管存在显著异质性（I=73%；P=0.002）。与 DD 组相比，NDND 组的远端闭塞比例明显更高（347 例中有 137 例（39.4%）和 428 例中有 47 例（11%）），研究间存在显著异质性（I=85%，p=0.023）。90 天功能独立性（mRS 0-2）在 DD 组中为 259 例中有 259 例（259 例中有 259 例）和 NDND 组中为 197 例中有 197 例（668 例中有 197 例）（OR=1.12；95%CI 0.77，1.63；p=0.552），但也存在显著异质性（I=46%，p=0.063）。DD 组的症状性颅内出血（sICH）发生率较低，309 例中有 14 例（4.9%），而 NDND 组 400 例中有 47 例（11.7%）（OR=0.49；95%CI 0.25，0.93；p=0.029），与 NDND 患者相比无差异，但不存在异质性（I=0%，p=0.552）。90 天死亡率在 DD 组中为 43 例中有 43 例（43 例中有 43 例）和 NDND 组中为 107 例中有 107 例（399 例中有 107 例）（OR=0.55；95%CI 0.37，0.82；p=0.004），与 NDND 患者相比无显著异质性（I=0%，p=0.536）。
本荟萃分析表明，DD 和 NDND 患者的功能独立性率相当。然而，NDND 患者的远端闭塞比例较高，sICH 和死亡率较高，提示在不满足 DAWN/DEFUSE-3 标准的情况下，对机械血栓切除术应持谨慎态度。对 EVT 资格标准采取更灵活的方法可能有益于真实世界实践中的选择患者。然而，仍需要进一步研究以确定哪些患者将从扩大 EVT 资格标准中受益。
