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Original research
Stroke imaging prior to thrombectomy in the late window: results from a pooled multicentre analysis
  1. Mohammed A Almekhlafi1,
  2. John Thornton2,
  3. Ilaria Casetta3,
  4. Mayank Goyal4,
  5. Stefania Nannoni5,
  6. Darragh Herlihy6,
  7. Enrico Fainardi7,
  8. Sarah Power8,
  9. Valentina Saia9,
  10. Aidan Hegarty6,
  11. Giovanni Pracucci10,
  12. Andrew Demchuk4,
  13. Salvatore Mangiafico11,
  14. Karl Boyle6,
  15. Patrik Michel5,
  16. Fouzi Bala4,
  17. Rubina Gill4,
  18. Andrea Kuczynski12,
  19. Ayolla Ademola4,
  20. Michael D Hill13,
  21. Danilo Toni14,
  22. Sean Murphy15,
  23. Beom Joon Kim16,
  24. Bijoy K Menon17
  25. for the Selection Of Late-window Stroke for Thrombectomy by Imaging Collateral Extent (SOLSTICE) Consortium
  1. 1 Departments of Clinical Neurosciences, Radiology, and Community Health Sciences. Hotchkiss Brain Institute and O’Brien Institute for Public Health, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
  2. 2 Neuroradiology Department, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
  3. 3 Clinica Neurologica, University of Ferrara, Ferrara, Italy
  4. 4 Departments of Clinical Neurosciences, Radiology, and Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
  5. 5 Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
  6. 6 Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
  7. 7 Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Toscana, Italy
  8. 8 Interventional Neuroradiology Service, Neuroradiology Department, Beaumont Hospital, Dublin, Leinster, Ireland
  9. 9 Neurology and Stroke Unit, Hospital Santa Corona, Pietra Ligure, Liguria, Italy
  10. 10 Stroke Unit, Careggi University Hospital, Florence, Italy
  11. 11 Neuroradiologia, University Hospital Careggi, Firenze, Toscana, Italy
  12. 12 Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
  13. 13 Departments of Clinical Neurosciences, Radiology, Community Health Sciences, and Medicine. Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
  14. 14 Department of Human Neuroscience; Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
  15. 15 Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, School of Medicine, Royal College of Surgeons in Ireland, University College Dublin, Dublin, Ireland
  16. 16 Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Bundang-gu, Gyeonggi-do, Republic of Korea
  17. 17 Departments of Clinical Neurosciences, Radiology, and Community Health Sciences. Hotchkiss Brain Institute, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Mohammed A Almekhlafi, Foothills Medical Centre, Calgary, Canada; mohammed.almekhlafi1{at}ucalgary.ca

Abstract

Background and purpose Collateral assessment using CT angiography is a promising modality for selecting patients for endovascular thrombectomy (EVT) in the late window (6–24 hours). The outcome of these patients compared with those selected using perfusion imaging is not clear.

Methods We pooled data from seven trials and registries of EVT-treated patients in the late-time window. Patients were classified according to the baseline imaging into collateral imaging alone (collateral cohort) and perfusion plus collateral imaging (perfusion cohort). The primary outcome was the proportion of patients achieving independent 90-day functional outcome (modified Rankin Scale ‘mRS’ 0–2). We used the propensity score–weighting method to balance important predictors between the cohorts.

Results In 608 patients, the median onset/last-known-well to emergency arrival time was 8.8 hours and 53.2% had wake-up strokes. Both cohorts had collateral imaging and 379 (62.3%) had perfusion imaging. Independent functional outcome was achieved in 43.1% overall: 168/379 patients (45.5%) in the perfusion cohort versus 94/214 (43.9%) in the collateral cohort (p=0.71). A logistic regression model adjusting for inverse-probability-weighting showed no difference in 90-day mRS score of 0–2 among the perfusion versus collateral cohorts (adjusted OR 1.05, 95% CI 0.69 to 1.59, p=0.83) or in a favourable shift in 90-day mRS (common adjusted OR 1.01, 95% CI 0.69 to 1.47, p=0.97).

Conclusion This pooled analysis of late window EVT showed comparable functional outcomes in patients selected for EVT using collateral imaging alone compared with patients selected using perfusion and collateral imaging.

PROSPERO registration number CRD42020222003.

  • stroke
  • image analysis
  • interventional
  • cerebrovascular

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Correction notice This article has been corrected since it first published. A colon has been added to the title for clarity.

  • Contributors MAA and BKM conceived the manuscript idea and organised the data collection. MAA, BJK, AA and BKM developed the statistical analysis plan and performed the analyses. The rest of the coauthors participated in the data collection from their respective registries and trials. MAA drafted the manuscript. All authors discussed the results and contributed to the final manuscript. MAA acts as guarantor and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MAA reports being a member of the scientific advisory board of Palmera Medical. AD reports personal fees from Medtronic. MG reports grants or personal fees from Medtronic, Stryker, Microvention, Cerenovus, and has a patent Systems of Acute Stroke Diagnosis issued to GE Healthcare. MDH has received grant support from Medtronic, consultant fees from Boehringer Ingelheim and speaker’s fees from Amgen. SM acted as a consultant for Cerenovus. BKM reports shares in Circle NVI; patent for systems of triage in acute stroke. Dr Patrik reports research grants from the Swiss Heart Foundation and the Swiss National Science Foundation. DT received honoraria as a member of advisory board of Abbott, Boehringer Ingelheim, Bayer, Pfizer-BMS, Medtronic and Daiichi Sankyo. The other authors report no conflicts.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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