Leaving the day behind: endovascular therapy beyond 24 h in acute stroke of the anterior and posterior circulation

There is little evidence of endovascular therapy (EVT) being performed in acute ischemic stroke beyond 24 h, and that evidence is limited to anterior circulation stroke.To extend evidence of efficacy and safety of EVT after more than 24 h in both anterior and posterior circulation stroke.Local, prospectively collected registries were screened for patients with acute ischemic stroke and large-vessel occlusion who had received either EVT > 24 h after last-seen-well but <24 h after symptom recognition (EVT>24LSW) or EVT > 24 h since first (definitive) symptom recognition (EVT>24DEF). Patients treated <24 h served as a group for comparison. Favorable outcome was defined as modified Rankin scale (mRS) 0-2 or return to prestroke mRS at 3 months.Between January 2014 and August 2021, N = 2347 were treated with EVT at our comprehensive stroke center, of whom n = 43 met the inclusion criteria (EVT>24LSW, n = 16, EVT>24DEF, n = 27). EVT>24LSW patients were treated at a median of 28.7 h [interquartile range (IQR) = 27.3-32.8] after last-seen-well and 7.3 h (IQR = 2.8-14.3) after symptom recognition; EVT>24DEF patients were treated 52.5 h (IQR = 26.5-94.2) after first symptoms. Favorable outcome was achieved by 23.3% (10/43) in the EVT > 24 compared with 39.4% (886/2250) in the EVT < 24 group (p = 0.04). Bleeding rates were similar across groups. Mortality was also similar [EVT > 24, 27.9% (12/43) versus EVT < 24, 25.7% (584/2264), p = 0.727; posterior circulation, EVT > 24, 41.7% (5/12) versus EVT < 24, 36.5% (92/252) p = 0.764].In selected patients, EVT seems effective and safe beyond 24 h for both anterior and posterior circulation stroke.