Endovascular Thrombectomy Beyond 24 Hours from Stroke Onset: A Systematic Review and Meta-Analysis
Aaron Rodriguez-Calienes1, Juan Vivanco-Suarez1, Milagros Galecio-Castillo1, Cynthia Zevallos1, Marco Malaga1, Mudassir Farooqui1, Santiago Ortega Gutierrez2
1Department of Neurology, 2Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics
Objective:
To assess the safety and efficacy of endovascular thrombectomy (EVT) >24-h and compare clinical outcomes with patients treated <24-h.
Background:
Trials have demonstrated the benefit of EVT up to 24-hours after acute ischemic stroke (AIS) onset. Recently, real-world observational studies reported that EVT was effective and safe beyond 24-h from AIS onset with comparable outcomes to EVT within 24-h.
Design/Methods:
A systematic search was performed in MEDLINE and EMBASE for studies published from inception to July 2022. Studies including patients with AIS who received EVT beyond 24-h from stroke onset were selected. We also included patients treated with EVT (>24-h and <24-h) from our institutional retrospective data. Outcomes of interest included functional independence (90-day mRS 0-2), successful recanalization (mTICI 2b-3), symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days. First, a single-arm meta-analysis (MA) of proportions was conducted for studies with EVT >24-h. Then, we performed a comparative MA between the <24-h and >24-h groups to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I2 statistics.
Results:
Five studies with 298 patients treated >24-h were included. Functional independence rate was 39% (95%CI 27–54%; I2=68%) and successful recanalization rate was 79% (95%CI 75–83%; I2=0%). Mortality and sICH rates were 25% (95%CI 20–30%; I2=0%) and 6% (95%CI 4–9%; I2=0%), respectively. We included 3272 patients (>24-h = 179; <24-h = 3093) in the comparative analysis. There was no significant difference in functional independence (OR 0.76; 95%CI 0.41–1.32), successful recanalization (OR 0.6; 95%CI 0.44–1.0), and mortality (OR 1.18; 95%CI 0.7–1.9) rates between patients who underwent EVT <24-h versus >24-h.
Conclusions:
Our findings prove that EVT beyond 24-h is safe and effective. Also, this MA did not demonstrate a significant difference between EVT beyond and within 24-h from stroke onset regarding functional independence, successful recanalization, and mortality.