PURPOSE: We aimed to assess the safety and effectiveness of mechanical recanalization in patients with ischemic stroke in the anterior circulation within 8 h since symptoms onset and with unknown onset time. We compared time intervals <6 h vs. 6-8 h/unknown onset time, as only limited data are available for a time window beyond 6 h. METHODS: Our cohort included 110 consecutive patients (44 males; mean age, 73.0±11.5 years) with ischemic stroke in the anterior circulation due to the acute occlusion of a large intracranial artery who underwent mechanical recanalization within an 8-hour time window or with unknown onset time. All patients underwent unenhanced computed tomography (CT) of the brain, CT angiography of the cervical and intracranial arteries and digital subtraction angiography. Perfusion CT was performed in patients beyond a 6-hour time window/with unknown onset time. We collected the following data: baseline characteristics, presence of risk factors, neurologic deficit at the time of treatment, time to therapy, recanalization rate, and 3-month clinical outcome. Successful recanalization was defined as Thrombolysis in Cerebral Infarction score of 2b/3 and good clinical outcome as modified Rankin scale value of 0-2 points. RESULTS: Successful recanalization was achieved in 82 patients (74.5%): in 61 patients treated within 6 h (73.5%), 7 patients treated within 6-8 h (63.6%), and 13 patients with unknown onset time (81.3%). Good 3-month clinical outcome was achieved in 61 patients (55.5%): in 46 patients treated within 6 h (55.4%), 5 patients treated within 6-8 h (45.5%), and 10 patients with unknown onset time (62.5%). Recanalization success or clinical outcome were not significantly different between patients treated at different time windows. CONCLUSION: Our data confirms the safety and effectiveness of mechanical recanalization performed in carefully selected patients with ischemic stroke in the anterior circulation within 8 h of stroke onset or with unknown onset time in everyday practice.

Departments of Neurology Comprehensive Stroke Center Charles University Faculty of Medicine and University Hospital Hradec Králové Czech Republic

See more in PubMed

Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998;352:1245–1251. https://doi.org/10.1016/S0140-6736(98)08020-9. PubMed DOI

Lees KR, Bluhmki E, von Kummer R, et al. ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695–1703. https://doi.org/10.1016/S0140-6736(10)60491-6. PubMed DOI

Christou J, Burgin WS, Alexandrov AV, Grotta JC. Arterial status after intravenous TPA therapy for ischaemic stroke: a need for further investigations. Int Angiol. 2001;20:208–213. PubMed

Saqqur M, Uchino K, Demchuk AM, et al. CLOTBUST Investigators. Site of arterial occlusion identified by transcranial doppler predicts the response to intravenous thrombolysis for stroke. Stroke. 2007;38:948–954. https://doi.org/10.1161/01.STR.0000257304.21967.ba. PubMed DOI

Alexandrov AV, Molina CA, Grotta JC, et al. CLOTBUST Investigators. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004;351:2170–2178. https://doi.org/10.1056/NEJMoa041175. PubMed DOI

Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38:967–973. https://doi.org/10.1161/01.STR.0000258112.14918.24. PubMed DOI

Broderick JP, Palesch YY, Demchuk AM, et al. Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368:893–903. https://doi.org/10.1056/NEJMoa1214300. PubMed DOI PMC

Ciccone A, Valvassori L, Nichelatti M, et al. SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368:904–913. https://doi.org/10.1056/NEJMoa1213701. PubMed DOI PMC

Kidwell CS, Jahan R, Gornbein J, et al. MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914–923. https://doi.org/10.1056/NEJMoa1212793. PubMed DOI PMC

Parsons MW, Albers GW. MR RESCUE. Is the glass half-full or half-empty? Stroke. 2013;44:2055–2057. https://doi.org/10.1161/STROKEAHA.113.001443. PubMed DOI

Campbell BCV, Oxley TJ, Chapot R. Acute ischemic stroke. Time, penumbra, and reperfusion. Stroke. 2014;45:640–644. https://doi.org/10.1161/STROKEAHA.113.003798. PubMed DOI

Berkhemer OA, Fransen PS, Beumer D, et al. MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. https://doi.org/10.1056/NEJMoa1411587. PubMed DOI

Campbell BC, Mitchell PJ, Kleinig TJ, et al. EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–1018. https://doi.org/10.1056/NEJMoa1414792. PubMed DOI

Goyal M, Demchuk AM, Menon BK, et al. ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–1030. https://doi.org/10.1056/NEJMoa1414905. PubMed DOI

Saver JL, Goyal M, Bonafe A, et al. SWIFT PRIME Investigators. SolitaireTM with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke. 2015;10:439–448. https://doi.org/10.1111/ijs.12459. PubMed DOI PMC

Jovin TG, Chamorro A, Cobo E, et al. REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. https://doi.org/10.1056/NEJMoa1503780. PubMed DOI

Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355:1670–1674. https://doi.org/10.1016/S0140-6736(00)02237-6. PubMed DOI

Campbell BC, Christensen S, Levi CR, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke. 2011;42:3435–3440. https://doi.org/10.1161/STROKEAHA.111.618355. PubMed DOI

Neumann J, Tomek A, Školoudík D, et al. Doporučený postup pro intravenózní trombolýzu v léčbě akutního mozkového infarktu – verze 2014. Cesk Slov Neurol. 2014;77/110:381–385.

Sanák D, Nosál’ V, Horák D, et al. Impact of diffusion-weighted MRI-measured initial cerebral infarction volume on clinical outcome in acute stroke patients with middle cerebral artery occlusion treated by thrombolysis. Neuroradiology. 2006;48:632–639. https://doi.org/10.1007/s00234-006-0105-0. PubMed DOI

Goldstein LB, Samsa GP. Reliability of the National Institute of Health Stroke Scale. Extension to non-neurologists in the kontext of a clinical trial. Stroke. 1997;28:307–310. https://doi.org/10.1161/01.STR.28.2.307. PubMed DOI

Yoo AJ, Simonsen CZ, Prabhakaran S, et al. Cerebral Angiographic Revascularization Grading Collaborators. Refining angiographic biomarkers of revascularization. Improving outcome prediction after intra-arterial therapy. Stroke. 2013;44:2509–2512. https://doi.org/10.1161/STROKEAHA.113.001990. PubMed DOI PMC

Hong KS, Saver JL. Quantifying the value of stroke disability outcomes. WHO Global Burden of Disease Project disability weights for each level of the modified Rankin scale. Stroke. 2009;40:3828–3833. https://doi.org/10.1161/STROKEAHA.109.561365. PubMed DOI PMC

Pierot L, Derdeyn C. Interventionalist perspective on the new endovascular trials. Stroke. 2015;46:1440–1446. https://doi.org/10.1161/STROKEAHA.115.008416. PubMed DOI

Grotta JC, Hacke W. Stroke neurologist’s perspective on the new endovascular trials. Stroke. 2015;46:1447–1452. https://doi.org/10.1161/STROKEAHA.115.008384. PubMed DOI

Campbell BC, Yassi N, Ma H, et al. Imaging selection in ischemic stroke: feasibility of automated CT-perfusion analysis. Int J Stroke. 2015;10:51–54. https://doi.org/10.1111/ijs.12381. PubMed DOI

Menon BJ, Campbell BCV, Levi Ch, Goral M. Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke. 2015;46:1453–1461. https://doi.org/10.1161/STROKEAHA.115.009160. PubMed DOI

Jauch EC, Saver JL, Adams HP, Jr, et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947. https://doi.org/10.1161/STR.0b013e318284056a. PubMed DOI

Šaňák D, Neumann J, Tomek A, et al. Doporučení pro rekanalizační léčbu akutního mozkového infarktu – verze 2016. Cesk Slov Neurol. 2016;79/112:231–234. https://doi.org/10.14735/amcsnn2016231. DOI

Acute Management Should Be Optimized in Patients with Less Specific Stroke Symptoms: Findings from a Retrospective Observational Study