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Original research
Simplified selection criteria for patients with longer or unknown time to treatment predict good outcome after mechanical thrombectomy
  1. Simon Nagel1,
  2. Christian Herweh2,
  3. Johannes Alex Rolf Pfaff2,
  4. Simon Schieber1,
  5. Silvia Schönenberger1,
  6. Markus A Möhlenbruch2,
  7. Martin Bendszus2,
  8. Peter Arthur Ringleb1
  1. 1 Department of Neurology, University of Heidelberg, Heidelberg, Germany
  2. 2 Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
  1. Correspondence to Dr Simon Nagel, Department of Neurology, University Hospital Heidelberg, INF 400, Heidelberg 69120, Germany; simon.nagel{at}


Objective To identify simplified selection criteria for mechanical thrombectomy (MT) in longer and unknown time windows.

Methods Patients with large vessel occlusion (LVO) in the anterior circulation who underwent MT between January 2014 and November 2017 were identified from the local registry. Patients were selected for analysis if they met the current guideline recommendation for MT treatment except for time window (HERMES-like) and were divided according to time they were last seen well (LSW): LSW <6 hours or LSW >6 hours before MT. The primary endpoint, good outcome, was modified Rankin scale score 0–2 on day 90. Safety outcomes were mortality on day 90 and symptomatic intracranial hemorrhage (sICH). Univariate and multivariate analysis were performed for good outcome in HERMES-like patients.

Results In total, 752 patients were identified and 390 patients (51.9%) fulfilled the HERMES-like criteria. Despite differences in baseline parameters, more diffusion-weighted imaging (DWI) (43.9% vs 11.3%, p<0.001) and fewer cases of thrombolysis (32.7% vs 77%, p<0.001), patients LSW >6 hours (n=107) did not differ in the primary and secondary endpoints: good outcome (44.9% vs 44.9%, p=1.0), mortality (14% vs 15.2%, p=0.87), and sICH (5.6% vs 6%, p=1.0). After multivariate regression analysis, independent predictors of good outcome remained: age, OR=0.96 (95% CI 0.95 to 0.98); National Institutes of Health Stroke Scale score, OR=0.92 (95% CI 0.89 to 0.96); Alberta Stroke Programme Early CT Score (ASPECTS), OR=1.26 (95% CI 1.06 to 1.49); general anesthesia, OR=0.2 (95% CI 0.04 to 0.99), and successful recanalization, OR=12 (95% CI 4.7 to 30.5); but not treatment time and DWI or CT perfusion at baseline.

Conclusion Patients with proven LVO in unknown and longer time windows may be selected for MT based on ASPECTS and clinical criteria.

  • thrombectomy
  • stroke
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  • SN and CH contributed equally.

  • Contributors All authors contributed substantially to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work AND in drafting the work or revising it critically for important intellectual content AND gave their final approval of the version to be published. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • 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 Outside the published work, personal fees, travel support, speaker honoraria, or research grants were received from Acandis (MAM), Bayer (MB, PAR, SN), Brainomix (SN, CH), BMS Pfizer (MB, PAR, SN), Boehringer Ingelheim (MB, PAR, SN), Codman (MB, MAM), Medtronic (MAM, SN, MB), Deutsche Forschungsgesellschaft (MB, PAR), Guerbet (MB), Hopp foundation (MB), Microvention (MAM), Phenox (MAM), Roche (MB), Siemens (MB, JARP) and Stryker (CH, JARP, MAM), TEVA (MB), Vascular Dynamics (MB).

  • Patient consent Not required.

  • Ethics approval Heidelberg ethics committee.

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

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