title: A multicenter study of the safety and effectiveness of mechanical thrombectomy for patients with acute ischemic stroke not meeting top-tier evidence criteria.
abstract: BACKGROUND
  While mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke (AIS) with emergent large-vessel occlusions (ELVO), recently published guidelines appropriately award top-tier evidence to the same selective criteria that were employed in completed clinical trials. We sought to evaluate the safety and effectiveness of MT in patients with AIS with ELVO who do not meet top-tier evidence criteria (TTEC).
  
  
  METHODS
  We conducted an observational study on consecutive patients with AIS with ELVO who underwent MT at six high-volume endovascular centers. Standard safety outcomes (3-month mortality, symptomatic intracranial hemorrhage) and effectiveness outcomes (3-month functional independence: modified Rankin Scale scores of 0-2) were compared between patients meeting and failing TTEC.
  
  
  RESULTS
  The sample consisted of 349 (60%) controls fulfilling TTEC and 234 (40%) non-TTEC patients. Control patients meeting TTEC for MT tended to have higher functional independence rates at 3 months (47% vs 39%; p=0.055), while the rates of symptomatic intracerebral hemorrhage (sICH) were similar (9%) in both groups (p=0.983). In multivariable logistic regression models, adherence to TTEC for MT was not independently related to any safety outcome (sICH: OR 0.71, 95% CI 0.30 to 1.68, p=0.434; 3-month mortality: OR 1.27, 95% CI 0.69 to 2.33, p=0.448) or effectiveness outcome (3-month functional independence: OR 0.81, 95% CI 0.48 to 1.37, p=0.434; 3-month functional improvement: OR 0.73, 95% CI 0.48 to 1.11, p=0.138) after adjusting for potential confounders.
  
  
  CONCLUSIONS
  Approximately 40% of patients with AIS with ELVO offered MT do not fulfill TTEC for MT. Patients who did not meet TTEC had high rates of good clinical outcome and low complication rates.
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Nitin
authors.initials: N
authors.lastname: Goyal
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.|Second Department of Neurology, "Attikon University Hospital", School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.|International Clinical Research Center, St. Anne's Hospital, Brno, Czech Republic.
authors.forename: Georgios
authors.initials: G
authors.lastname: Tsivgoulis
authors.affiliation: Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA.
authors.forename: Donald
authors.initials: D
authors.lastname: Frei
authors.affiliation: Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
authors.forename: Aquilla
authors.initials: A
authors.lastname: Turk
authors.affiliation: Department of Interventional Neuroradiology, Erlanger Hospital, Chattanooga, Tennessee, USA.
authors.forename: Blaise
authors.initials: B
authors.lastname: Baxter
authors.affiliation: Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Froehler
authors.affiliation: Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA.
authors.forename: J
authors.initials: J
authors.lastname: Mocco
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA.
authors.forename: Jay
authors.initials: J
authors.lastname: Vachhani
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Hoit
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.|Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA.
authors.forename: Lucas
authors.initials: L
authors.lastname: Elijovich
authors.affiliation: Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA.
authors.forename: David
authors.initials: D
authors.lastname: Loy
authors.affiliation: Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
authors.forename: Raymond D
authors.initials: RD
authors.lastname: Turner
authors.affiliation: Department of Neurosurgery, Mount Sinai Medical Center, New York, New York, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Mascitelli
authors.affiliation: Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA.
authors.forename: Kiersten
authors.initials: K
authors.lastname: Espaillat
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
authors.forename: Andrei V
authors.initials: AV
authors.lastname: Alexandrov
authors.affiliation: Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.|Australian Catholic University, Sydney, New South Wales, Australia.
authors.forename: Anne W
authors.initials: AW
authors.lastname: Alexandrov
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee, USA.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Arthur
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D061185:Mechanical Thrombolysis / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy*; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome
keywords: Stroke; Thrombectomy