Aristeidis H. Katsanos, MD
Jadhav AP, Desai SM, Kenmuir CL, Rocha M, Starr MT, Molyneaux BJ, et al. Eligibility for Endovascular Trial Enrollment in the 6- to 24-Hour Time Window: Analysis of a Single Comprehensive Stroke Center. Stroke. 2018
Results of the DAWN (Diffusion-Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke-3) trials were incorporated into the recently published guidelines on acute ischemic stroke (AIS) management from the American Heart Association/American Stroke Association, which strongly suggest treatment with mechanical thrombectomy in patients with anterior circulation large vessel occlusion presenting within 6 to 16 hours of symptom onset, if satisfying DAWN or DEFUSE 3 eligibility criteria (Class of Recommendation: I, Level of Evidence A), while proposing treatment with mechanical thrombectomy in patients with anterior circulation large vessel occlusion within 6 to 24 hours of symptom onset, if eligible according to the criteria of the DAWN trial (Class of Recommendation: IIa, Level of Evidence B).
In the aforementioned study, the authors retrospectively reviewed all AIS admissions to a single comprehensive stroke center, participating in the DAWN trial. They found that approximately one-third of all patients present 6-24 hours after AIS onset, while estimating that according to the eligibility criteria of the DAWN and DEFUSE 3 trials, one out of three patients with large vessel occlusion and 5.7% of all patients with AIS presenting within 6-24 hours after AIS onset could be eligible for endovascular treatment. More specifically, from all AIS patients included in this retrospective registry, 1.7% were found to meet DAWN eligibility criteria, while an additional 0.6% to 1% was found to qualify for the DEFUSE 3 trial criteria. Approximately one third of these patients was found to satisfy the eligibility criteria of both the DAWN and DEFUSE 3 trials, while one third of DAWN-eligible patients were found to be DEFUSE 3 ineligible.
Expanding treatment indications for patients with large vessel occlusion based on both DAWN and DEFUSE 3 criteria would inevitably result in a significant increase in thrombectomy utilization for AIS patients, which should be promptly supported by analogous modifications in stroke system care at both the national and institutional level.