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Endovascular Reperfusion Therapy and Acute Ischemic Stroke Outcomes
Study Questions:
What is the association of speed of treatment with outcome among patients with acute ischemic stroke (AIS) undergoing endovascular-reperfusion therapy?
Methods:
The investigators conducted a retrospective cohort study using data prospectively collected from January 2015 to December 2016 in the Get With The Guidelines-Stroke nationwide US quality registry, with final follow-up through April 15, 2017. Participants were 6,756 patients with anterior circulation large vessel occlusion AIS treated with endovascular-reperfusion therapy with onset-to-puncture time of ≤8 hours. Data on onset (last-known well time) to arterial puncture, and hospital arrival to arterial puncture (door-to-puncture time) were collected. The main outcome measures were substantial reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), ambulatory status, global disability (modified Rankin Scale [mRS]) and destination at discharge, symptomatic intracranial hemorrhage (sICH), and in-hospital mortality/hospice discharge. The relationships between onset-to-puncture and door-to-puncture times and the binary outcomes were assessed using logistic regression models with restricted cubic splines of onset-to-puncture or door-to-puncture times.
Results:
Among 6,756 patients, the mean (standard deviation) age was 69.5 (14.8) years, 51.2% (3,460/6,756) were women, and median pretreatment score on the National Institutes of Health Stroke Scale was 17 (interquartile range [IQR], 12-22). Median onset-to-puncture time was 230 minutes (IQR, 170-305) and median door-to-puncture time was 87 minutes (IQR, 62-116), with substantial reperfusion in 85.9% (5,433/6324) of patients. Adverse events were sICH in 6.7% (449/6,693) of patients and in-hospital mortality/hospice discharge in 19.6% (1,326/6,756) of patients. At discharge, 36.9% (2,132/5,783) ambulated independently and 23.0% (1,225/5,334) had functional independence (mRS 0-2).
In onset-to-puncture adjusted analysis, time-outcome relationships were nonlinear with steeper slopes between 30-270 minutes than 271-480 minutes. In the 30- to 270-minute time frame, faster onset to puncture in 15-minute increments was associated with higher likelihood of achieving independent ambulation at discharge (absolute increase, 1.14%; 95% confidence interval [CI], 0.75%-1.53%), lower in-hospital mortality/hospice discharge (absolute decrease, −0.77%; 95% CI, −1.07% to −0.47%), and lower risk of sICH (absolute decrease, −0.22%; 95% CI, −0.40% to −0.03%). Faster door-to-puncture times were similarly associated with improved outcomes, including in the 30- to 120-minute window, higher likelihood of achieving discharge to home (absolute increase, 2.13%; 95% CI, 0.81%-3.44%) and lower in-hospital mortality/hospice discharge (absolute decrease, −1.48%; 95% CI, −2.60% to −0.36%) for each 15-minute increment.
Conclusions:
The authors concluded that shorter time to endovascular-reperfusion therapy was significantly associated with better outcomes.
Perspective:
This exploratory study reports that among patients with AIS due to large vessel occlusion, earlier endovascular-reperfusion therapy was significantly associated with better outcomes, including independent ambulation at discharge, discharge to home, functional independence, and freedom from disability at discharge and at 3 months, and with lower complications, including in-hospital mortality and sICH. Furthermore, the pace of the reduction in benefit associated with longer onset-to-puncture time intervals was nonlinear for most of the outcomes, with a more rapid benefit loss in the first 30-270 minutes and a slower decline between 271-480 minutes after witnessed stroke onset. These and other contemporary data support efforts to reduce time to hospital and endovascular treatment in patients with stroke with faster activation of emergency medical services by witnesses, by prehospital personnel efficiently routing patients to thrombectomy-capable hospitals, and with rapid triage and treatment of patients within systems of care.
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, Coronary Occlusion, Endovascular Procedures, Hospices, Hospital Mortality, Intracranial Hemorrhages, Outcome Assessment, Health Care, Reperfusion, Secondary Prevention, Stroke, Thrombectomy, Vascular Diseases
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