Novel selection paradigms for endovascular stroke treatment in the extended time window

Background and Purpose: The optimal selection methodology for stroke thrombectomy beyond 6 hours is yet to be determined.

Methods: A review was conducted on a prospectively collected database of thrombectomy patients with anterior circulation strokes, NIHSS ≥10, and CT perfusion maps, who presented beyond 6 hours (January 2014 to October 2018). Patients were categorized by five selection paradigms: DAWN-CCM, DEFUSE-3-PIM, and three ASPECTS-based criteria (aCAM, eCAM, sCAM).

Results: 310 patients were analyzed. DEFUSE-3-PIM identified the highest proportion of qualifying patients (93.5%), followed by sCAM, eCAM, aCAM, and DAWN-CCM (92.6%, 90.6%, 90%, 84.5%). Patients meeting aCAM, eCAM, sCAM, and DAWN-CCM had significantly higher rates of 90-day good outcomes than non-qualifying patients; no significant difference was seen for DEFUSE-3-PIM. Multivariate analysis showed all modalities except DEFUSE-3-PIM were independently associated with better 90-day outcome.

Conclusions: ASPECTS-based selection paradigms for late-presenting and wake-up stroke thrombectomy yield similar proportions of qualifying patients and 90-day outcomes as DAWN-CCM and DEFUSE-3-PIM, and may offer an alternative for centers with limited access to advanced imaging.