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Impact of Procedure Time on Stroke Outcomes
Study Questions:
What is the impact of endovascular thrombectomy (ET) procedure time on outcomes after stroke with large vessel occlusion?
Methods:
This was an analysis of a prospectively maintained database of acute ischemic stroke patients with large vessel occlusion who underwent ET at seven comprehensive stroke centers in the United States over 4.5 years. ET could include mechanical thrombectomy with stent retrievers (SRs) or direct aspiration thrombectomy (ADAPT). Procedure time was defined as the length of time from groin puncture to either thrombolysis in cerebral infarction (TICI) 2B flow or procedure abortion. The main outcomes of interest were good functional outcome (modified Rankin scale score 0-2) and post-procedural symptomatic intracranial hemorrhage (sICH).
Results:
A total of 1,357 patients were included in this study. Increasing procedure time was associated with a decreasing likelihood of good functional outcome and increasing likelihood of sICH. A transition point was observed at 30 minutes, after which the cumulative rate of good functional outcome dropped by 40%. After 60 minutes, the cumulative rate of good functional outcome plateaued, and every 5% increase in the cumulative rate of good functional outcome was accompanied by a 200% increase in the rate of sICH. After adjustment for potential confounders, procedure time <30 minutes was an independent predictor of good functional outcome at 90 days (adjusted odds ratio [aOR], 1.55; 95% confidence interval [CI], 1.14-2.09) and of lower sICH rate (aOR, 0.47; 95% CI, 0.24-0.93). ADAPT as a first-pass technique was associated with a significantly shorter procedure time (35 minutes vs. 59 minutes for SR; p < 0.001) and better rates of final TICI score 2C/3 (55% vs. 23%; p < 0.01).
Conclusions:
In this observational study, longer ET procedure time was associated with worse functional outcomes and a higher risk of sICH. ADAPT may be superior to SR, as it is associated with shorter procedure times. After 60 minutes of procedure time, a careful assessment of the benefits and risks of continuing ET should be undertaken.
Perspective:
It is not surprising that longer ET procedure time is associated with worse clinical outcomes, given that longer procedure time is likely associated with longer cerebral ischemia from the occluded vessel, more diseased cervical and intracranial vessels (likely a surrogate for worse clinical status), longer time under anesthesia, etc. The faster recanalization times seen with ADAPT over SR could be further investigated in a randomized controlled trial, with randomization of large vessel occlusion patients to either ADAPT or SR as first-pass therapy. Given the diminishing returns and increasing risk of sICH observed after 60 minutes of procedure time, it is reasonable to perform a formal re-evaluation of the appropriateness of continuing the procedure at that time.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine
Keywords: Brain Ischemia, Cerebral Infarction, Endovascular Procedures, Intracranial Hemorrhages, Outcome Assessment, Health Care, Risk Assessment, Secondary Prevention, Stents, Stroke, Thrombectomy, Vascular Diseases
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