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Updated: Sep 7, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Yield of ASPECTS and Collateral CTA Selection for Mechanical Thrombectomy within 6-24 hours from Symptom Onset in a
Balaji Krishnaiah1, Demi Dawkins2, Vincent N Nguyen2
1Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
Insights
Mechanical thrombectomy for extended window large vessel occlusions is feasible using pragmatic imaging criteria. This approach identified eligible patients and demonstrated successful recanalization rates.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Stroke Medicine
Background:
- Extended window trials support mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (LVOs) with clinical-radiographic dissociation.
- Trial imaging criteria limit eligibility to 6% in hub-and-spoke systems.
- Pragmatic selection criteria may increase MT eligibility in extended time windows.
Purpose of the Study:
- To examine the eligibility and outcomes of mechanical thrombectomy in consecutive patients with anterior circulation LVOs presenting within an extended 6-24 hour window.
- To evaluate the effectiveness of pragmatic imaging criteria for patient selection.
Main Methods:
- Retrospective analysis of single-institution data for anterior circulation LVO patients (6-24h window).
- Mechanical thrombectomy performed based on non-contrast CT head ASPECTS ≥ 6 and/or CTA collateral scores ASITN/SIR 2-4.
- Primary outcomes: post-MT TICI 2b-3, 3-month mRS. Safety outcomes: in-hospital mortality, symptomatic intracerebral hemorrhage (sICH).
Main Results:
- 48/767 (6%) patients with anterior circulation LVOs underwent MT within the 6-24h window.
- Mean age 63±17, 56% male, median NIHSS 16, median ASPECTS 9, 79% had good CTA collaterals.
- Successful recanalization (mTICI 2b-3) in 73%, sICH in 6%, in-hospital mortality 25%, 3-month mRS 0-2 in 40%.
Conclusions:
- Pragmatic imaging selection (ASPECTS ≥6 with CTA collateral grade) is effective for identifying eligible patients for MT in the extended time window.
- This approach aligns with established hospital imaging protocols.
- Supports wider application of MT in extended time windows for LVOs.
Background:
Recent extended window trials support the benefit of mechanical thrombectomy in anterior circulation large vessel occlusions with clinical-radiographic dissociation. Using trial imaging criteria, 6% were found eligible for MT in the EW in a hub-and-spoke system. We examined the eligibility and outcomes in consecutive extended window-mechanical thrombectomy patients using more pragmatic selection criteria.
Methods:
We retrospectively analyzed single-institution data of anterior circulation large vessel occlusions patients presenting between 6-24 h who underwent mechanical thrombectomy based on a priori determined criteria including non-contrast CT head ASPECTS ≥ 6 and/or CTA collateral scores ASITN/SIR 2-4. Primary outcomes consisted of post-mechanical thrombectomy TICI 2b-3 and 3-month modified Rankin scores; safety outcomes consisted of in-hospital mortality and symptomatic intracerebral hemorrhage.
Results:
767 consecutive acute ischemic strokes patients presented within the 6-24 hour window, and of these 48 (6%) anterior circulation large vessel occlusions patients underwent mechanical thrombectomy. In this cohort the mean age was 63±17 years, 56% were male, the median NIHSS was 16 [IQR 10-19], the median ASPECTS was 9 (IQR 8-10), and 79% (n=38) had good CTA collaterals. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed symptomatic intracerebral hemorrhage. In-hospital mortality was 25% (n=12) while 40% (n=19) achieved 3-month modified Rankin Scores 0-2.
Conclusions:
Our data suggest the use of pragmatic imaging approach of ASPECTS ≥6 with CTA collateral grade in extended time window which is already established in most hospitals.
