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NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes
  1. Telma Santos1,
  2. Andreia Carvalho1,
  3. André Almeida Cunha2,
  4. Marta Rodrigues2,
  5. Tiago Gregório3,
  6. Ludovina Paredes3,
  7. Henrique Costa1,3,
  8. José Mário Roriz4,
  9. João Pinho5,
  10. Miguel Veloso1,3,
  11. Sérgio Castro2,
  12. Pedro Barros1,3,
  13. Manuel Ribeiro2
  1. 1 Department of Neurology, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal
  2. 2 Department of Imagiology, Neuroradiology Unit, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
  3. 3 Stroke Unit, Centro Hospitalar de Vila Nova de Gaia Espinho, Vila Nova de Gaia, Portugal
  4. 4 Department of Neurology, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
  5. 5 Department of Neurology, Hospital de Braga, Braga, Portugal
  1. Correspondence to Dr Pedro Barros, Stroke Unit, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia 4434-510, Portugal; pedrojgbarros{at}


Introduction Recently, the benefit of selecting patients for endovascular treatment (EVT) beyond the 6-hour time window using a tissue-based approach was demonstrated in two randomized trials. The optimal imaging protocol for selecting patients is under debate, and it is still unknown if a simpler and faster protocol may adequately select patients with wake-up stroke (WUS) and late-presenting stroke (LPS) for EVT.

Objective To compare outcomes of patients submitted to EVT presenting within 6 hours of symptom onset or 6–24 hours after last seen well, selected using non-contrast computed tomography (NCCT) and CT angiography (CTA).

Methods An observational study was performed, which included consecutive patients with anterior circulation ischemic stroke with large vessel occlusion treated with EVT. Patients presenting within 6 hours were treated if their NIH Stroke Scale (NIHSS) score was ≥6 and Alberta Stroke Program Early CT score (ASPECTS) was ≥6, while patients presenting with WUS or 6–24 hours after last seen well (WUS/LPS) were treated if their NIHSSscore was ≥12 and ASPECTS was ≥7.

Results 249 patients were included, 63 of whom were in the WUS/LPS group. Baseline characteristics were similar between groups, except for longer symptom-recanalization time, lower admission NIHSS (16 vs 17, P=0.038), more frequent tandem occlusions (25.4% vs 11.8%, P=0.010), and large artery atherosclerosis etiology (22.2% vs 11.8%, P=0.043) in the WUS/LPS group. No differences in symptomatic intracranial hemorrhage, peri-procedural complications or mortality were found between groups. Three-month functional independence was similar in both groups (65.1% in WUS/LPS vs 57.0% in ≤6 hours, P=0.259) and no differences were found after adjustment for confounders.

Conclusions This real-world observational study suggests that EVT may be safe and effective in patients with WUS and LPS selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).

  • stroke
  • intervention
  • thrombectomy

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  • Contributors TS, JP: study design, data collection, statistical analysis, and writing the manuscript. AC, MR: data collection and writing the manuscript. AAC: study design, data collection, and writing the manuscript. TG: statistical analysis and writing the manuscript. LP, HC, JMR, MV, SC, MR: study design and correction of manuscript. PB: study design, data collection and correction of manuscript.

  • 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 None declared.

  • Patient consent Not required.

  • Ethics approval Comissão de ética do Centro Hospitalar Vila Nova de Gaia/Epinho.

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

  • Data sharing statement Any information regarding unpublished data can be made available, opon request, by the corresponding author.