Endovascular Thrombectomy Beyond Six Hours in Anterior Circulation Large Vessel Occlusion
DOI:
https://doi.org/10.5281/zenodo.22310336Keywords:
Thrombectomy, Large vessel occlusion, Extended time window, Wake-up stroke, Perfusion imagingAbstract
Background: Mechanical thrombectomy is standard of care for anterior-circulation large vessel occlusion (LVO) stroke treated
within roughly six hours of onset, but many patients present later or with unknown onset time.
Objective: To review trial and post-trial evidence for thrombectomy beyond six hours, including wake-up stroke.
Methods: Narrative review of randomised trials, pooled analyses, imaging-selection studies, registries and guidelines.
Findings: DAWN and DEFUSE 3 used clinical-core and perfusion mismatch, respectively, to select patients 6-24 hours from onset,
each halted early for efficacy, with functional-independence rates roughly triple those of medical management. The AURORA
meta-analysis and MR CLEAN-LATE, using simpler collateral-based imaging, confirmed and extended this benefit.
Number-needed-to-treat for functional independence is approximately 3-4. Registry data show growing, cost-effective real-world
uptake. Symptomatic haemorrhage and futile recanalisation remain relevant harms.
Conclusions: Imaging-based, not clock-based, selection extends thrombectomy's benefit well beyond six hours and is now
incorporated into major guidelines, though optimal imaging strategy and patient selection remain active areas of refinement.
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