Armghan Ans: Beyond 24 Hours – Can Thrombectomy Still Benefit Stroke Patients?
Armghan Ans, Assistant Professor and Director of Stroke at UPMC Washington, Founder of MDAdopt, shared on LinkedIn:
“A patient with a large-vessel stroke arrives more than 24 hours after last known well. Is the thrombectomy conversation automatically over?
LATE-MT, published this month in NEJM, gives us a reason to ask a better question: what does the tissue look like?
In this NEJM trial, 336 patients with anterior-circulation LVO and salvageable tissue on perfusion imaging were randomized to EVT plus standard care or standard care alone between 24 and 72 hours. Median time to randomization was 38.5 hours.
The result was encouraging. At 90 days, thrombectomy produced a favorable shift across the full modified Rankin Scale (common OR 1.74; 95% CI 1.19–2.55).
The safety findings deserve the same attention. Symptomatic intracranial hemorrhage occurred in 4.8% of the EVT group versus 0% with medical care, and 90-day mortality was 6.0% versus 1.8%. We cannot discuss the functional benefit without acknowledging those differences.
What does this mean at the bedside? It reinforces that the clock alone does not tell the whole story. Some patients are slower progressors, and advanced imaging can reveal a treatment opportunity we might otherwise miss. But ’tissue is brain’ does not make ‘time is brain’ obsolete.
It makes selection and shared decision-making even more important.
This is one randomized trial from China, not a blanket mandate to extend thrombectomy to 72 hours. We need replication and careful evaluation of the safety signal before broad changes in practice.
What safeguards would your stroke team want in place before considering EVT beyond 24 hours?”
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