Is thrombectomy beneficial for extra-window anterior circulation stroke?

The study found that the benefit of endovascular therapy in patients 6-24 hours after onset was non-inferior to the benefit of treatment in the early time window within 6 hours of onset
.

However, individual study populations are underrepresented, and uncertainty remains about the benefits of endovascular therapy
.

A recent study conducted a patient-level meta-analysis of randomized controlled trials of thrombectomy in patients with large vessel occlusion in the anterior circulation of more than 6 hours onset to provide a more comprehensive understanding of whether thrombectomy is beneficial for anterior circulation stroke beyond the time window
.

STUDY INTRODUCTION We conducted a systematic review and meta-analysis of individual case data of randomized controlled trials of endovascular treatment of acute ischemic stroke with onset over 6 hours between January 1, 2010, and March 1, 2021
.

The primary outcome was the modified Rankin Scale (mRS) score at 90 days, analyzed by logistic regression
.

Key safety outcomes were symptomatic intracerebral hemorrhage and 90-day mortality
.

 Findings ➤ Patient-level data were included for 505 patients who met inclusion criteria (n=266 interventions, n=239 controls, mean age 68.
6 years [SD 13.
7], 259 [51.
3%] women)
.

The primary outcome analysis showed that the unadjusted odds ratio (OR) for the benefit of thrombectomy was 2.
42 (95%CI 1.
76-3.
33; p<0.
0001), and the variable-adjusted odds ratio (OR) was 2.
54 (95%CI 1.
83) -3.
54; p<0.
0001), adjusting for age, sex, baseline NIHSS score, baseline head CT ASPECTS score, and time from onset to randomization
.

 ➤ Compared with optimal medical therapy alone, thrombectomy was more associated with function-independent outcomes (mRS 0-2 points) (45.
9% vs 19.
3%; p<0.
0001)
.

 ➤ When analyzing 90-day mortality (16.
5% vs 19.
3%) and symptomatic intracerebral hemorrhage (5.
3% vs 3.
3%), no significant differences were found between the intervention and control groups
.

 ➤ No heterogeneity in treatment effect was found among subgroups assigned according to age, sex, baseline stroke severity, vascular occlusion site, baseline ASPECTS score, and disease modality
.

 ➤ Patients within 12-24 hours of onset (OR 5.
86 [95% CI 3.
14-10.
94]) had better treatment outcomes than patients within 6-12 hours (OR 1.
76 [95% CI 1.
18-2.
62]; p=0.
0087)
.

 Conclusions: This study reinforces the evidence that endovascular thrombectomy is beneficial in patients with ischemic stroke in the 6-24 hour time window of onset, and is relevant to clinical practice
.

The results of this study suggest that thrombectomy should not be discontinued based on disease severity or onset time window
.

 Compiled by: Jovin TG, Nogueira RG, Lansberg MG, Demchuk AM, Martins SO, Mocco J, Ribo M, Jadhav AP, Ortega-Gutierrez S, Hill MD, Lima FO, Haussen DC, Brown S, Goyal M, Siddiqui AH, Heit JJ, Menon BK, Kemp S, Budzik R, Urra X, Marks MP, Costalat V, Liebeskind DS, Albers GW.
Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis.
Lancet.
2022 Jan 15;399(10321):249-258.
doi: 10.
1016/S0140-6736(21)01341-6.
Epub 2021 Nov 11.
PMID: 34774198.