J Clin Neurol.  2019 Apr;15(2):168-174. 10.3988/jcn.2019.15.2.168.

The Clinical Benefit and Care Burden of Extending the Window of Endovascular Thrombectomy for Stroke in the Emergency Room

• Yang W
• Kang DW
• Gook HS
• Ha S
• Lee SH

• KMID: 2467730
• DOI: http://doi.org/10.3988/jcn.2019.15.2.168

Abstract

BACKGROUND AND PURPOSE
The recent successes of the DAWN and DEFUSE 3 trials have extended the therapeutic time window for endovascular treatment (EVT). Accordingly, an increased care burden and clinical benefit for patients with acute stroke in the emergency room are expected. It is necessary to evaluate and respond to these changes in order to provide the best care to patients.
METHODS
Data of patients with acute stroke or transient ischemic attack treated at Seoul National University Hospital between October 2010 and September 2016 were reviewed. To estimate the increased workload associated with the revised guidelines, clinical candidates of acute stroke based on the initial history and examination findings and eligible patients for early stroke intervention were selected. Additionally, the data of eligible patients who received EVT more than 6 hours after the onset were reviewed.
RESULTS
The serial addition of intravenous thrombolysis, EVT within 6 hours, and EVT beyond 6 hours to the guidelines resulted in 506 (19.8%), 588 (23.0%), and 718 (28.0%) clinical candidates, respectively, and 329 (12.8%), 365 (14.3%), and 389 (15.2%) eligible patients out of 2,561 patients with stroke. Compared to applying the previous stroke guidelines, the number of clinical candidates increased by 130 (22.1%), whereas the number of eligible patients for early stroke intervention increased by only 24 (6.6%). Seven of the 24 eligible patients received off-label EVT and showed significantly improved neurological outcomes at discharge.
CONCLUSIONS
Notwithstanding the small number of subjects in this study, providing EVT to eligible patients beyond 6 hours may improve their neurological outcomes.

Keyword

stroke; endovascular procedures; thrombectomy; emergency medical services; healthcare costs

MeSH Terms

Emergencies*
Emergency Medical Services
Emergency Service, Hospital*
Endovascular Procedures
Health Care Costs
Humans
Ischemic Attack, Transient
Seoul
Stroke*
Thrombectomy*

Figure

• 

  Fig. 1 The number of beneficiaries of EVT was increased and EVT beyond 6 hours from onset improved neurological outcomes of selected patients. A: Clinical candidates and eligible patients selected by the criteria for categories 1, 2, and 3; 506 (19.8%) of 2,561 patients were designated as category 1 clinical candidates, and 588 (23.0%) patients were clinical candidates who met the criteria for category 1 or 2. The number of clinical candidates satisfying at least one of the criteria for category 1, 2, or 3 was 718 (28.0%). Totals of 329 (12.8%), 365 (14.3%), and 389 (15.2%) patients were eligible according to the criteria for category 1, category 1 or 2, and category 1, 2, or 3, respectively. B: Neurological status at admission and discharge according to off-label EVT beyond 6 hours from the last known normal time. The initial deficits were similar in the two groups, but the neurological symptoms at discharge were significantly improved in those who received off-label EVT. The horizontal line inside the box represents the median, the box shows the interquartile range, and the vertical lines represent the interquartile range extended to 1.5 times. *p<0.05. EVT: endovascular treatment, IV rtPA: intravenous recombinant tissue plasminogen activator, NIHSS: National Institutes of Health Stroke Scale, ns: not significant.

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