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Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis
  1. Aaron Rodriguez-Calienes1,2,
  2. Milagros Galecio-Castillo1,
  3. Juan Vivanco-Suarez1,
  4. Ghada A Mohamed3,
  5. Gabor Toth4,
  6. Amrou Sarraj5,
  7. Deep Pujara5,
  8. AJ A Chowdhury1,
  9. Mudassir Farooqui1,
  10. Malik Ghannam1,
  11. Edgar A Samaniego6,
  12. Tudor G Jovin7,
  13. Santiago Ortega-Gutierrez6
  1. 1 Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2 Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
  3. 3 Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
  5. 5 Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  6. 6 Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  7. 7 Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
  1. Correspondence to Dr Santiago Ortega-Gutierrez, Neurology, Neurosurgery and Radiology, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA; santy-ortega{at}


Background Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available.

Methods A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0–2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model.

Results Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours.

Conclusions EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.

  • Thrombectomy
  • Stroke
  • Intervention

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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  • X @AaronCalienes, @mili_galecio, @jsvivanco1, @GaborTothMD, @amrsarrajMD, @FunkyMegacolon, @esamaniego, @CerebrovascLab

  • Contributors All authors contributed to the study design and drafting of the manuscript. The search was completed by ARC, JVS, and MGC; screening of articles by ARC, JVS, and MGC; data extraction by ARC, JVS, MGC, and AAC; quality control by ARC, JVS, and AAC; statistical analysis by MGC and ARC; data interpretation by ARC, JVS, MF, and SOG; critical revision by GAM, GT, AS, DP, MF, MG, EAS, TGJ, and SOG. SOG is responsible for the overall content as guarantor.

  • 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 SOG: grants from NIH, Stryker, Medtronic, Microvention, MEthinks, IschemiaView,, Siemens; consulting fees from Medtronic and Stryker. TGJ: advisor and investor for Anaconda, Route92, Viz.AI, FreeOx, Blockade Medical, and Methinks; grant support from Medtronic and from Stryker Neurovascular in his capacity as principal investigator for DAWN and AURORA; he received personal fees in his role on the Data Safety Monitoring Board. GT: consultant: Dynamed and Micronvention. AS: principal investigator of the SELECT (Optimizing Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke) and SELECT-2 trials through a grant from Stryker Neurovascular to the University of Texas McGovern–Houston; consultant: Stryker; speaker bureau member: Stryker.

  • 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.