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Thrombectomy’s success treating strokes prompts rethinking of selection criteria


 

EXPERT ANALYSIS FROM ISC 2018


Dr. Gregory Albers of Stanford University Jim Kling/Frontline Medical News

Dr. Gregory W. Albers

The new U.S. acute stroke guidelines call for close adherence to the DAWN and DEFUSE 3 enrollment criteria. That means in patients 6-16 hours out from their stroke onset, the criteria from either trial can apply (DEFUSE 3 enrolled patients 6-16 hours out, while DAWN enrolled patients from the 6-24 hours window), and in general that means following the DEFUSE 3 criteria, which were less restrictive. Gregory W. Albers, MD, professor of neurology and director of the stroke center at Stanford (Calif.) University and lead investigator for DEFUSE 3 noted that roughly 40% of the patients enrolled in his trial would not have qualified for DAWN.

That’s because DEFUSE 3 enrolled patients with a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 6, while patients in DAWN required a score of at least 10, a loosening that allowed inclusion of 31 patients with scores of 6-9 in DEFUSE 3. Another, less restrictive criterion was the patient’s prestroke mRS score, which could have been 0-2 in DEFUSE 3 but could be only 0-1 in DAWN. Thirteen of the DEFUSE 3 patients had prestroke mRS scores of 2. DEFUSE 3 also had somewhat more liberal criteria for the size of a patient’s infarcted core at enrollment, with 41 patients who would have been excluded from DAWN because of an overly large infarcted core, Dr. Albers said in his presentation at the conference.

Currently, for patients presenting more than 16 hours following their stroke onset but within 24 hours, the DAWN enrollment criteria exclusively determine which patients should get thrombectomy.

One area where these rules could be bent is by a more thoughtful approach to the prestroke mRS score rule out, such as patients with orthopedic or rheumatic complications that limit mobility and give them an mRS score of 3. “We don’t have data for patients with back pain who can’t walk. I currently take these patients to endovascular therapy, and I’m sure many others do, too,” Dr. Khatri said.

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