Endovascular treatment beyond 24 hours for large vessel occlusion strokes selected by CT perfusion

Background The role that endovascular treatment (EVT) may play in stroke patients with large vessel occlusion (LVO) who are treated beyond 24 hours after onset is unclear. In this study, we aimed to examine the efficacy and safety of EVT beyond 24 hours based on uniform CT perfusion criteria in appropriately selected patients. Methods A retrospective review was performed at a single stroke center between January 2020 and August 2023. We chose patients who received EVT beyond 24 hours via CT perfusion. A matched group of patients who received EVT within the 6–24 hour time window was chosen as a control. Functional independence (modified Rankin scale score ≤ 2) at 90 days was used as the primary outcome, and symptomatic intracranial hemorrhage (sICH)and mortality were considered safety outcomes. Results We selected 400 patients treated with EVT within the 6–24 hour time window and 82 patients treated beyond 24 hours. A 2:1 matched group was used for comparison. No significant differences in functional independence (58.5% vs. 61.6%, P  = 0.645), safety outcomes of sICH (7.3% vs. 9.8%, P  = 0.527), or mortality (2.4% vs. 3.0%, P  = 0.786) at 90 days were demonstrated. Patients who underwent EVT beyond 24 hours had a greater incidence of large-artery atherosclerosis (LAA) (89.0% vs. 75.6%; P  = 0.044) and a course of neurological deterioration before EVT (78.0% vs. 43.7%; P  < 0.001). According to multivariate analysis, the preoperative NIHSS score (OR = 0.770, P  = 0.001), sex (OR = 4.569, P  = 0.007), and pro-operative ND (OR = 27.192, P  = 0.006) were associated with good outcomes. Conclusions Compared with endovascular treatment performed within the 6–24 hours, EVT beyond 24 hours appears to be feasible and safe for acute LVO stroke patients who meet the DEFUSE-3 imaging criteria based on CT perfusion. Patients with neurological deterioration during the course of the disease may be a suitable screening population for super late window EVT.