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. Weber; Rohan Chitale; John J. Volpi; Stephan A. Mayer; Shadi Yaghi; Mahesh Jayaraman; Pooja Khatri; Eva A. Mistry

doi:10.1093/neuros/nyz485

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 journal › Article › peer-review

14 Scopus citations

Abstract

BACKGROUND: 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 language	English (US)
Pages (from-to)	E156-E163
Journal	Clinical Neurosurgery
Volume	86
Issue number	2
DOIs	https://doi.org/10.1093/neuros/nyz485
State	Published - Feb 1 2020

Bibliographical note

Funding Information:
This study was supported by a Society of Vascular and Interventional Neurology (SVIN) pilot grant, University of Cincinnati Gardner Neuroscience Institute pilot grant, StrokeNet NCC (U01 NS086872), and StrokeNet University of Cincinnati RCC (U10 NS086512). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Publisher Copyright:
© 2019 by the Congress of Neurological Surgeons.

Keywords

Acute stroke
Computed tomography
Perfusion imaging
Thrombectomy
Prospective Studies
Humans
Middle Aged
Stroke/diagnostic imaging
Male
Thrombectomy/methods
Treatment Outcome
Aged, 80 and over
Female
Aged
Brain Ischemia/diagnostic imaging
Cohort Studies

PubMed: MeSH publication types

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

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10.1093/neuros/nyz485

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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

Siegler, JE, Messé, SR, Sucharew, H, Kasner, SE, Mehta, T, Arora, N, Starosciak, AK, De Los Rios La Rosa, F, Barnhill, NR, Mistry, AM, Patel, K, Assad, S, Tarboosh, A, Dakay, K, Salwi, S, Wagner, J, Bennett, A, Jagadeesan, BD , Streib, C, Weber, SA, Chitale, R, Volpi, JJ, Mayer, SA, Yaghi, S, Jayaraman, M, Khatri, P & Mistry, EA 2020, 'Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis from the BEST Prospective Cohort Study', Clinical Neurosurgery, vol. 86, no. 2, pp. E156-E163. https://doi.org/10.1093/neuros/nyz485

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

abstract = "BACKGROUND: 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.",

keywords = "Acute stroke, Computed tomography, Perfusion imaging, Thrombectomy, Prospective Studies, Humans, Middle Aged, Stroke/diagnostic imaging, Male, Thrombectomy/methods, Treatment Outcome, Aged, 80 and over, Female, Aged, Brain Ischemia/diagnostic imaging, Cohort Studies",

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

note = "Funding Information: This study was supported by a Society of Vascular and Interventional Neurology (SVIN) pilot grant, University of Cincinnati Gardner Neuroscience Institute pilot grant, StrokeNet NCC (U01 NS086872), and StrokeNet University of Cincinnati RCC (U10 NS086512). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Publisher Copyright: {\textcopyright} 2019 by the Congress of Neurological Surgeons.",

year = "2020",

month = feb,

day = "1",

doi = "10.1093/neuros/nyz485",

language = "English (US)",

volume = "86",

pages = "E156--E163",

journal = "Neurosurgery",

issn = "0148-396X",

publisher = "Lippincott Williams and Wilkins",

number = "2",

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TY - JOUR

T1 - Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients

T2 - A Subgroup Analysis from the BEST Prospective Cohort Study

AU - Siegler, James E.

AU - Messé, Steven R.

AU - Sucharew, Heidi

AU - Kasner, Scott E.

AU - Mehta, Tapan

AU - Arora, Niraj

AU - Starosciak, Amy K.

AU - De Los Rios La Rosa, Felipe

AU - Barnhill, Natasha R.

AU - Mistry, Akshitkumar M.

AU - Patel, Kishan

AU - Assad, Salman

AU - Tarboosh, Amjad

AU - Dakay, Katarina

AU - Salwi, Sanjana

AU - Wagner, Jeff

AU - Bennett, Alicia

AU - Jagadeesan, Bharathi D.

AU - Streib, Christopher

AU - Weber, Stewart A.

AU - Chitale, Rohan

AU - Volpi, John J.

AU - Mayer, Stephan A.

AU - Yaghi, Shadi

AU - Jayaraman, Mahesh

AU - Khatri, Pooja

AU - Mistry, Eva A.

N1 - Funding Information: This study was supported by a Society of Vascular and Interventional Neurology (SVIN) pilot grant, University of Cincinnati Gardner Neuroscience Institute pilot grant, StrokeNet NCC (U01 NS086872), and StrokeNet University of Cincinnati RCC (U10 NS086512). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Publisher Copyright: © 2019 by the Congress of Neurological Surgeons.

PY - 2020/2/1

Y1 - 2020/2/1

N2 - BACKGROUND: 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.

AB - BACKGROUND: 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.

KW - Acute stroke

KW - Computed tomography

KW - Perfusion imaging

KW - Thrombectomy

KW - Prospective Studies

KW - Humans

KW - Middle Aged

KW - Stroke/diagnostic imaging

KW - Male

KW - Thrombectomy/methods

KW - Treatment Outcome

KW - Aged, 80 and over

KW - Female

KW - Aged

KW - Brain Ischemia/diagnostic imaging

KW - Cohort Studies

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U2 - 10.1093/neuros/nyz485

DO - 10.1093/neuros/nyz485

M3 - Article

C2 - 31758197

AN - SCOPUS:85077941724

SN - 0148-396X

VL - 86

SP - E156-E163

JO - Neurosurgery

JF - Neurosurgery

IS - 2

ER -

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

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