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Thrombectomy 6 to 24 Hours after Stroke.

To the Editor: The results of the DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) trial reported by Nogueira et al. (Jan. 4 issue)1 show the advantage of basing the decision to perform thrombectomy in patients with acute ischemic strokes on the presence of salvageable penumbral tissue instead of on a prespecified time window. We wonder whether screening-failure logs before randomization show that this approach may have benefited only a small percentage of patients who presented more than 6 hours after the onset of stroke. The high proportion of patients who woke up with stroke symptoms (approximately 55%) in the trial also raises the possibility that “6 hours after the patient was last known to be well” may not always mean “6 hours after the onset of stroke.” Some clinical and imaging studies indicate that “wake-up strokes” occur close to the time of awakening.2 This finding would have put the control group in the DAWN trial at a disadvantage, since some patients in both groups could have been in the established window period for thrombectomy. Data on the time interval from awakening to intervention could be revealing.