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Mechanical thrombectomy for large vessel occlusion strokes beyond 24 hours
  1. Amir Shaban1,
  2. Sami Al Kasab2,
  3. Reda M Chalhoub3,
  4. Eric Bass4,
  5. Ilko Maier5,
  6. Marios-Nikos Psychogios6,
  7. Ali Alawieh7,
  8. Stacey Q Wolfe8,
  9. Adam S Arthur9,10,
  10. Travis M Dumont11,
  11. Peter Kan12,
  12. Joon-tae Kim13,
  13. Reade De Leacy14,
  14. Joshua W Osbun15,
  15. Ansaar T. Rai16,
  16. Pascal Jabbour17,
  17. Min S Park18,
  18. Roberto Javier Crosa19,
  19. Justin R Mascitelli20,
  20. Michael R Levitt21,
  21. Adam J Polifka22,
  22. Walter Casagrande23,
  23. Shinichi Yoshimura24,
  24. Charles Matouk25,
  25. Richard Williamson26,
  26. Benjamin Gory27,
  27. Maxim Mokin28,
  28. Isabel Fragata29,
  29. Daniele G Romano30,
  30. Shakeel A Chowdhry31,
  31. Mark Moss32,
  32. Daniel Behme33,
  33. Kaustubh Limaye34,
  34. Alejandro M Spiotta3,
  35. Edgar A Samaniego35
  1. 1 Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2 Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
  5. 5 Neurology, University Medicine Goettingen, Goettingen, Germany
  6. 6 Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  7. 7 Neurosurgery, Emory University, Atlanta, Georgia, USA
  8. 8 Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  9. 9 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  10. 10 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  11. 11 Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  12. 12 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  13. 13 Chonnam National University Hospital, Seol, Korea (the Republic of)
  14. 14 Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
  15. 15 Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  16. 16 Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
  17. 17 Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  18. 18 Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  19. 19 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  20. 20 Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  21. 21 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  22. 22 Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  23. 23 Neurosurgery, Hospital Juan A. Fernandez, Buenos Aires, Argentina
  24. 24 Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  25. 25 Neurosurgery, Yale University, New Haven, Connecticut, USA
  26. 26 Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
  27. 27 Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
  28. 28 Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
  29. 29 Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  30. 30 Policlinico "Santa Maria alle Scotte", Unit of Neuroimaging and Neurointervention Siena, IT, University Hospital of Siena, Siena, Italy
  31. 31 NorthShore University HealthSystem, Evanston, Illinois, USA
  32. 32 Washington Regional Medical Center, Fayetteville, Arkansas, USA
  33. 33 Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
  34. 34 Neurology, Indiana University Bloomington, Bloomington, Indiana, USA
  35. 35 Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Amir Shaban, Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; amir-shaban{at}


Background Recent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window.

Methods A retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6–24-hour window. We used functional independence at 3 months as our primary outcome measure.

Results We identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6–24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6–24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022).

Conclusions Mechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.

  • Stroke
  • CT perfusion
  • Thrombectomy
  • Thrombolysis

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Correction notice Since this paper was first published, the author name Shakeel A Chowdry has been updated to Shakeel A Chowdhry.

  • Contributors All coauthors read and reviewed the manuscripts and agree with the publication. They all contributed to the study being published. Authors’ contributions:

    Guarantor: AS

    Concept design: AS, ES, AS

    Drafting manuscript: AS

    Data acquisition, revision, editing, approval of final draft: SK, RC, EB, IM, MP, AA,TD, SW,AA, PK, JK, RDL, JO, AR, PJ, MP, RC, JM, ML, AP, WC, SY, CM. RW, BG, MM, IF, DR, SC, MM, DB, KL

    Data analysis: RC

  • Funding STAR registry receives funding from Penumbra, Stryker and Medtronic.

  • Competing interests PK: consultant for Stryker NV and Imperative Care. On the editorial board of JNIS. DRG: Balt Italy: Consultant, Microvention Europe: Consultant, Penumbra Inc: Consultant. AMS: Penumbra: Research support, Consultant. Stryker: Research support, Consultant. Cerenovus: Consultant. Terumo: Consultant. IschemaView Inc/Rapid AI: Research support, Consultant. ASA: Consultant for Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker Research support from Balt, Medtronic, Microvention, Penumbra and Siemens Shareholder Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Serenity, Synchron, Triad Medical, Vastrax, VizAI. RDL: Consultant - Imperative Care, Stryker, Cerenovus, Spartan Micro. Research support – Siemens. On the editorial board of JNIS. ML: On the editorial board of JNIS. MM: On the editorial board of JNIS. JM: Consultant Stryker. On the editorial board of JNIS. MSP: Clinical Events Committee/Consultant for Medtronic. AP: consultant for Stryker and Depuy Synthes. ES: Consultant for Medtronic/Microvention/Rapid Medical.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.