Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis from the BEST Prospective Cohort Study

James E. Siegler, Steven R. Messé, Heidi Sucharew, Scott E. Kasner, Tapan Mehta, Niraj Arora, Amy K. Starosciak, Felipe De Los Rios La Rosa, Natasha R. Barnhill, Akshitkumar M. Mistry, Kishan Patel, Salman Assad, Amjad Tarboosh, Katarina Dakay, Sanjana Salwi, Jeff Wagner, Alicia Bennett, Bharathi D. Jagadeesan, Christopher Streib, Stewart A. WeberRohan Chitale, John J. Volpi, Stephan A. Mayer, Shadi Yaghi, Mahesh Jayaraman, Pooja Khatri, Eva A. Mistry

Research output: Contribution to journalArticle

2 Scopus citations

Abstract

Because of the overwhelming benefit of thrombectomy for highly selected trial patients with large vessel occlusion (LVO), some trial-ineligible patients are being treated in practice. OBJECTIVE: To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients. METHODS: Using a multicenter prospective observational study of consecutive patients with anterior circulation LVO who underwent late thrombectomy, we compared symptomatic intracerebral hemorrhage (sICH) and good outcome (90-d mRS 0-2) among DAWN/DEFUSE-3-ineligible patients to trial-eligible patients and to untreated DAWN/DEFUSE-3 controls. RESULTS: Ninety-eight patients had perfusion imaging and underwent thrombectomy >6 h; 46 (47%) were trial ineligible (41% M2 occlusions, 39% mild deficits, 28% ASPECTS <6). In multivariable regression, the odds of a good outcome (aOR 0.76, 95% CI 0.49-1.19) and sICH (aOR 3.33, 95% CI 0.42-26.12) were not different among trial-ineligible vs eligible patients. Patients with mild deficits were more likely to achieve a good outcome (aOR 3.62, 95% CI 1.48-8.86) and less sICH (0% vs 10%, P =. 16), whereas patients with ASPECTS <6 had poorer outcomes (aOR 0.14, 95% CI 0.05-0.44) and more sICH (aOR 24, 95% CI 5.7-103). Compared to untreated DAWN/DEFUSE-3 controls, trial-ineligible patients had more sICH (13%BEST vs 3%DAWN [P =. 02] vs 4%DEFUSE [P =. 05]), but were more likely to achieve a good outcome at 90 d (36%BEST vs 13%DAWN [P <. 01] vs 17%DEFUSE [P =. 01]). CONCLUSION: Thrombectomy is used in practice for some patients ineligible for the DAWN/DEFUSE-3 trials with potentially favorable outcomes. Additional trials are needed to confirm the safety and efficacy of thrombectomy in broader populations, such as large core infarction and M2 occlusions.

Original languageEnglish (US)
Pages (from-to)E156-E163
JournalClinical Neurosurgery
Volume86
Issue number2
DOIs
StatePublished - Feb 1 2020

Keywords

  • Acute stroke
  • Computed tomography
  • Perfusion imaging
  • Thrombectomy

PubMed: MeSH publication types

  • Journal Article
  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

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  • Cite this

    Siegler, J. E., Messé, S. R., Sucharew, H., Kasner, S. E., Mehta, T., Arora, N., Starosciak, A. K., De Los Rios La Rosa, F., Barnhill, N. R., Mistry, A. M., Patel, K., Assad, S., Tarboosh, A., Dakay, K., Salwi, S., Wagner, J., Bennett, A., Jagadeesan, B. D., Streib, C., ... Mistry, E. A. (2020). Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis from the BEST Prospective Cohort Study. Clinical Neurosurgery, 86(2), E156-E163. https://doi.org/10.1093/neuros/nyz485