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 journalArticlepeer-review

14 Scopus citations


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 languageEnglish (US)
Pages (from-to)E156-E163
JournalClinical Neurosurgery
Issue number2
StatePublished - 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.


  • 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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