Endovascular Thrombectomy versus Medical Management in Patients Presenting Beyond 24 Hours of Last Known Well and...

There is uncertainty regarding the effectiveness of endovascular thrombectomy (EVT) in patients presenting beyond 24 hours. We compared the clinical outcomes of these patients with FVH-DWI mismatch treated with EVT versus best medical management (BMM).

Consecutive patients meeting eligibility criteria were enrolled from an ongoing, prospective, multicenter TRACK-LVO Late cohort (January 2018 to December 2025). The primary outcome was 90-day functional independence. Safety outcomes included 90-day all-cause mortality, and symptomatic intracranial hemorrhage (sICH). Differences in outcomes were assessed using inverse probability of treatment weighting-adjusted logistic regression models.

Among 648 patients screened, 247 met inclusion criteria (median age 63 years [IQR: 55-70]; baseline NIHSS 10 [IQR: 8-13]). Of these, 132 (53%) received EVT and 115 (47%) received BMM. In IPTW-adjusted analyses, the EVT group had significantly higher odds of functional independence (aOR 3.05, 95% CI: 1.69-5.50; P < 0.001) and a favorable shift in mRS scores distribution (aOR: 2.26, 95% CI: 1.41-3.65; P < 0.001) compared to the BMM group. Mortality did not differ significantly between groups (aOR 0.49, 95% CI: 0.15-1.61; P = 0.241). However, EVT was associated with a significantly higher risk of sICH (6.8% vs. 0%; P = 0.012).

In patients with FVH-DWI mismatch, EVT was associated with better odds of functional independence, despite an increased risk of sICH. These results suggest that the FVH-DWI mismatch may be a useful imaging marker for selecting patients for EVT who present more than 24 hours.