Safety and effectiveness of endovascular therapy after 8 hours of acute ischemic stroke onset and wake-up strokes

Background and Purpose-: This is a retrospective review of patients who underwent endovascular recanalization ≥8 hours after acute ischemic stroke symptom onset, including wake-up strokes, between June 2005 and June 2008. Methods-: Thirty patients with a premorbid modified Rankin score ≤1 and NIHSS between 5 and 22 were included. All had admission CT, CTA, and CT perfusion scans to evaluate for salvageable brain tissue. Recanalization effectiveness was assessed by angiograms obtained within 30 hours after intervention. Patient, treatment characteristics, and immediate and 3-month outcomes were analyzed. Results-: Mean NIHSS at presentation was 13 (median=12). Mean interval between time last-seen well and angiogram was 12.75 hours (median=10). Twenty-six patients (86.7%) presented with complete-to-near-complete vessel occlusion (thrombolysis in myocardial infarction [TIMI] 0/1); 4 had partial vessel occlusion (TIMI 2). Interventions included intra-arterial pharmacological thrombolysis (n=10), mechanical thrombectomy(n=21; Merci, 16; intracranial stent, 9; extracranial stent, 3), angioplasty (n=14; intracranial, 11; extracranial, 3). Nine patients received GPIIb/IIIa inhibitors (eptifibatide); all received heparin. Partial-to-complete recanalization (TIMI 2/3) was achieved in 20 patients (66.7%). Procedure-related complications included vascular perforations (n=3) and femoral access site complication (n=1). One patient had an embolic anterior cerebral artery infarct during intervention; another had progression of brain stem infarct. Symptomatic intracerebral hemorrhage occurred in 3 patients (10%), with 2 being primarily subarachnoid in location. Total in-hospital mortality including procedural mortality, disease progression, or other comorbidities was 23.3% (n=7). Mean discharge NIHSS was 9.5, representing an overall NIHSS 3.5-point improvement. Overall, mean modified Rankin score at death or last follow-up (mean=10.6 months) was 4.2. At 3 months, total mortality was 33.3% (n=10), 20% had modified Rankin score ≤2, and 33% had modified Rankin score ≤3. Among survivors, mean modified Rankin score at 3-month follow-up was 3. Conclusion-: Our data show that delayed endovascular revascularization of carefully selected patients is safe, effective, and improves clinical outcome.