Guilherme B F Porto, Medical University of South Carolina
Ching-Jen Chen, Thomas Jefferson UniversityFollow
Sami Al Kasab, Medical University of South Carolina
Muhammed Amir Essibayi, Medical University of South Carolina
Eyad Almallouhi, Medical University of South Carolina
Zachary Hubbard, Medical University of South Carolina
Reda Chalhoub, Medical University of South Carolina
Ali Alawieh, Emory University
Ilko Maier, University Medical Center Göttingen
Marios-Nikos Psychogios, University of Basel
Stacey Q Wolfe, Wake Forest University
Pascal Jabbour, Thomas Jefferson UniversityFollow
Ansaar Rai, West Virginia University
Robert M Starke, University of Miami Health System
Amir Shaban, University of Iowa
Adam Arthur, University of Tennessee Health Science Center
Joon-Tae Kim, Chonnam National University Hospital
Shinichi Yoshimura, Hyogo College of Medicine
Jonathan Grossberg, Emory University
Peter Kan, University of Texas Medical Branch
Isabel Fragata, Hospital São José Centro Hospitalar
Adam Polifka, University of Florida
Joshua Osbun, Washington University in St Louis
Justin Mascitelli, University of Texas Health Science Center at San Antonio
Michael R Levitt, University of Washington
Richard Williamson, Allegheny Health Network
Daniele G Romano, A.O.U.S. Giovanni di Dio e Ruggi d'Aragona
Roberto Crosa, Endovascular Neurological Center
Benjamin Gory, Centre Hospitalier Régional Universitaire de Nancy
Maxim Mokin, University of South Florida
Kaustubh S Limaye, Indiana University
Walter Casagrande, Hospital Juan Fernandez
Mark Moss, Washington Regional Medical Center
Ramesh Grandhi, University of Utah
Albert Yoo, Texas Stroke Institute
Alejandro M Spiotta, Medical University of South Carolina
Min S Park, University of Virginia Health

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Publication Date



This article is the author’s final published version in JAMA network open, Volume 5, Issue 11, November 2022, Page e2241291.

The published version is available at Copyright © Porto et al.


Importance: There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.

Objective: To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).

Design, setting, and participants: In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.

Exposures: Selection by NCCT, CTP, or DWI.

Main outcomes and measures: Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days.

Results: Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.

Conclusions and relevance: In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

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This work is licensed under a Creative Commons Attribution 4.0 License.

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