From the Department of Neurology (T.N.N., P.K., Z.M.), and Department of Radiology (T.N.N., M.M.Q., M.A., P.K., Z.M.), Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, MA; Department of Neurology (R.G.N.), Neurosurgery, University of Pittsburgh Medical Center, PA; Department of Radiation Oncology (M.M.Q.), Boston Medical Center, MA; Department of Neurology (S. Nagel), Klinikum Ludwigshafen, Ludwigshafen, Germany; Department of Neurology (S. Nagel, P.A.R.), Heidelberg University Hospital, Germany; Interventional Neuroradiology Laboratory (J.R., D.R.), Department of Radiology, Centre Hospitalier de l'Universite de Montreal, Quebec, Canada; Department of Neurology (J.D., L.V., A.W., R.L.), UZ Leuven; Laboratory for Neurobiology (J.D., L.V., A.W., R.L.), KU Leuven, Belgium; Department of Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Department of Neurology (S.A.S., S.S.-M.), UTHealth McGovern Medical School, Houston, TX; Department of Neurology (V.P., S.W.), and Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Department of Neurology (A.D., F.B.), Hôpital Civil Marie Curie, Charleroi, Belgium; Department of Neurology (P.M., D. Strambo), Lausanne University Hospital and University of Lausanne, Switzerland; Department of Neurology (M. Ribo, M.O.-G., M. Requena), Hospital Vall d'Hebron, Barcelona, Spain; Neuroscience and Stroke Program (O.O.Z., E.L.), Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH; Department of Neurology (J.E.S.), University of Chicago, IL; Department of Neurology (D.C.H., M.H.M.), Grady Memorial Hospital, Atlanta, GA; Department of Neurology (D. Strbian, L.T., N.M.-M.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neurology (H.H., F.C., C.C.), Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France; Department of Radiology (M.A.M., J.J.), Heidelberg University Hospital, Germany; Division of Interventional Neuroradiology (A.S.P.), University of Massachusetts Memorial Medical Center, Worcester; Department of Diagnostic and Interventional Neuroradiology (J.K., A.M.), University Hospital Bern, Switzerland; Department of Radiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Department of Neurology (M.A.J., S.F.Z., A.C.C.), University of Toledo, OH; Department of Clinical Neurosciences (S. Nannoni), University of Cambridge, United Kingdom; Department of Neurology (M.F., S.O.-G.), University of Iowa, Iowa City; Department of Radiology (P.V., E.P.), Helsinki University Hospital, University of Helsinki, Finland; Institute of Neuroradiology (D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Department of Neurology (L.S., S.Y.), Rhode Island Hospital, Providence; Department of Neurology (Z.Q.), 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China; Department of Neurology (H.E.M.), State University of New York, Syracuse; Department of Neurology (W.H.), The First Affiliated Hospital of USTC, China; Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Stroke Neurology (H.Y.), NHO Osaka National Hospital, Japan; Department of Neurology (U.F.), University Hospital Basel, Switzerland; Department of Neurology (U.F.), University Hospital Bern, Switzerland; and Department of Neurology (T.G.J.), Cooper University Hospital, Camden, NJ.
Neurology. 2024 May 28;102(10):e209324. doi: 10.1212/WNL.0000000000209324. Epub 2024 May 6.
There is uncertainty whether patients with large vessel occlusion (LVO) presenting in the late 6-hour to 24-hour time window can be selected for endovascular therapy (EVT) by noncontrast CT (NCCT) and CT angiography (CTA) for LVO detection. We evaluated the clinical outcomes of patients selected for EVT by NCCT compared with those medically managed in the extended time window.
This multinational cohort study was conducted at 66 sites across 10 countries. Consecutive patients with proximal anterior LVO stroke selected for EVT by NCCT or medically managed and presenting within 6-24 hours of time last seen well (TSLW) from January 2014 to May 2022 were included. The primary end point was the 90-day ordinal shift in the modified Rankin Scale (mRS) score. Inverse probability treatment weighting (IPTW) and multivariable methods were used.
Of 5,098 patients screened, 839 patients were included, with a median (interquartile range) age of 75 (64-83) years; 455 (54.2%) were women. There were 616 patients selected to undergo EVT by NCCT (73.4%) and 223 (26.6%) who were medically managed. In IPTW analyses, there was a more favorable 90-day ordinal mRS shift in patients selected by NCCT to EVT vs those who were medically managed (odds ratio [OR] 1.99, 95% CI 1.53-2.59; < 0.001). There were higher rates of 90-day functional independence (mRS 0-2) in the EVT group (40.1% vs 18.4%, OR 3.31, 95% CI 2.11-5.20; < 0.001). sICH was nonsignificantly higher in the EVT group (8.5% vs 1.4%, OR 3.77, 95% CI 0.72-19.7, = 0.12). Mortality at 90 days was lower in the EVT vs MM group (23.9% vs 32.3%, OR 0.61, 95% CI 0.45-0.83, = 0.002).
In patients with proximal anterior LVO in the extended time window, there was a lower rate of disability and mortality in patients selected with NCCT and CTA to EVT compared with those who were medically managed. These findings support the use of NCCT as a simpler and more inclusive approach to patient selection in the extended window.
This study was registered at ClinicalTrials.gov under NCT04096248.
This study provides Class III evidence that for patients with proximal anterior circulation occlusion presenting with ischemic stroke from 6 to 24 hours, compared with medical management, those undergoing thrombectomy based on NCCT have reduced disability and mortality at 90 days.
对于发病时间在 6 至 24 小时窗内的大血管闭塞（LVO）患者，非对比 CT（NCCT）和 CT 血管造影（CTA）是否可以选择进行血管内治疗（EVT）存在不确定性。我们评估了通过 NCCT 选择 EVT 治疗的患者与在扩展时间窗内接受药物治疗的患者的临床结局。
这是一项在 10 个国家的 66 个地点进行的多国队列研究。连续纳入自 2014 年 1 月至 2022 年 5 月发病时间为最后一次可识别正常（TSLW）后 6-24 小时的近端前循环 LVO 卒中患者，根据 NCCT 或药物治疗选择 EVT 治疗，并进行了分组。主要终点是改良Rankin 量表（mRS）评分的 90 天有序变化。采用逆概率治疗加权（IPTW）和多变量方法。
在筛选的 5098 例患者中，839 例患者入选，中位（四分位间距）年龄为 75（64-83）岁；455 例（54.2%）为女性。616 例患者通过 NCCT 选择进行 EVT（73.4%），223 例（26.6%）接受药物治疗。在 IPTW 分析中，与药物治疗相比，通过 NCCT 选择进行 EVT 的患者 90 天 mRS 评分的改善更有利（比值比[OR]1.99，95%CI 1.53-2.59；<0.001）。EVT 组 90 天功能独立（mRS 0-2）的比例更高（40.1% vs. 18.4%，OR 3.31，95%CI 2.11-5.20；<0.001）。EVT 组 sICH 发生率无显著升高（8.5% vs. 1.4%，OR 3.77，95%CI 0.72-19.7，=0.12）。90 天死亡率 EVT 组低于 MM 组（23.9% vs. 32.3%，OR 0.61，95%CI 0.45-0.83，=0.002）。
在延长时间窗内的近端前循环 LVO 患者中，与药物治疗相比，通过 NCCT 和 CTA 选择 EVT 的患者残疾和死亡率较低。这些发现支持将 NCCT 作为一种更简单、更具包容性的方法，用于在延长时间窗内选择患者。
本研究提供了 III 级证据，对于发病时间在 6 至 24 小时窗内的前循环近端闭塞患者，与药物治疗相比，基于 NCCT 的血栓切除术可降低 90 天的残疾和死亡率。
