Marc Ribo1, Carlos A Molina2, Erik Cobo2, Neus Cerdà2, Alejandro Tomasello2, Helena Quesada2, Maria Angeles De Miquel2, Mónica Millan2, Carlos Castaño2, Xabier Urra2, Luis Sanroman2, Antoni Dàvalos2, Tudor Jovin2. 1. From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.). marcriboj@hotmail.com. 2. From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
Abstract
BACKGROUND AND PURPOSE: A progressive decline in the odds of favorable outcome as time to reperfusion increases is well known. However, the impact of specific workflow intervals is not clear. METHODS: We studied the mechanical thrombectomy group (n=103) of the prospective, randomized REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset) trial. We defined 3 workflow metrics: time from symptom onset to reperfusion (OTR), time from symptom onset to computed tomography, and time from computed tomography (CT) to reperfusion. Clinical characteristics, core laboratory-evaluated Alberta Stroke Program Early CT Scores (ASPECTS) and 90-day outcome data were analyzed. The effect of time on favorable outcome (modified Rankin scale, 0-2) was described via adjusted odds ratios (ORs) for every 30-minute delay. RESULTS:Median admission National Institutes of Health Stroke Scale was 17.0 (14.0-20.0), reperfusion rate was 66%, and rate of favorable outcome was 43.7%. Mean (SD) workflow times were as follows: OTR: 342 (107) minute, onset to CT: 204 (93) minute, and CT to reperfusion: 138 (56) minute. Longer OTR time was associated with a reduced likelihood of good outcome (OR for 30-minute delay, 0.74; 95% confidence interval [CI], 0.59-0.93). The onset to CT time did not show a significant association with clinical outcome (OR, 0.87; 95% CI, 0.67-1.12), whereas the CT to reperfusion interval showed a negative association with favorable outcome (OR, 0.72; 95% CI, 0.54-0.95). A similar subgroup analysis according to admission ASPECTS showed this relationship for OTR time in ASPECTS<8 patients (OR, 0.56; 95% CI, 0.35-0.9) but not in ASPECTS≥8 (OR, 0.99; 95% CI, 0.68-1.44). CONCLUSIONS: Time to reperfusion is negatively associated with favorable outcome, being CT to reperfusion, as opposed to onset to CT, the main determinant of this association. In addition, OTR was strongly associated to outcome in patients with low ASPECTS scores but not in patients with high ASPECTS scores. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.
RCT Entities:
BACKGROUND AND PURPOSE: A progressive decline in the odds of favorable outcome as time to reperfusion increases is well known. However, the impact of specific workflow intervals is not clear. METHODS: We studied the mechanical thrombectomy group (n=103) of the prospective, randomized REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset) trial. We defined 3 workflow metrics: time from symptom onset to reperfusion (OTR), time from symptom onset to computed tomography, and time from computed tomography (CT) to reperfusion. Clinical characteristics, core laboratory-evaluated Alberta Stroke Program Early CT Scores (ASPECTS) and 90-day outcome data were analyzed. The effect of time on favorable outcome (modified Rankin scale, 0-2) was described via adjusted odds ratios (ORs) for every 30-minute delay. RESULTS: Median admission National Institutes of Health Stroke Scale was 17.0 (14.0-20.0), reperfusion rate was 66%, and rate of favorable outcome was 43.7%. Mean (SD) workflow times were as follows: OTR: 342 (107) minute, onset to CT: 204 (93) minute, and CT to reperfusion: 138 (56) minute. Longer OTR time was associated with a reduced likelihood of good outcome (OR for 30-minute delay, 0.74; 95% confidence interval [CI], 0.59-0.93). The onset to CT time did not show a significant association with clinical outcome (OR, 0.87; 95% CI, 0.67-1.12), whereas the CT to reperfusion interval showed a negative association with favorable outcome (OR, 0.72; 95% CI, 0.54-0.95). A similar subgroup analysis according to admission ASPECTS showed this relationship for OTR time in ASPECTS<8 patients (OR, 0.56; 95% CI, 0.35-0.9) but not in ASPECTS≥8 (OR, 0.99; 95% CI, 0.68-1.44). CONCLUSIONS: Time to reperfusion is negatively associated with favorable outcome, being CT to reperfusion, as opposed to onset to CT, the main determinant of this association. In addition, OTR was strongly associated to outcome in patients with low ASPECTS scores but not in patients with high ASPECTS scores. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.
Authors: Johannes Pfaff; Silvia Schönenberger; Christian Herweh; Mirko Pham; Simon Nagel; Peter Arthur Ringleb; Sabine Heiland; Martin Bendszus; Markus Alfred Möhlenbruch Journal: Eur Radiol Date: 2017-02-17 Impact factor: 5.315
Authors: D Sacks; B Baxter; B C V Campbell; J S Carpenter; C Cognard; D Dippel; M Eesa; U Fischer; K Hausegger; J A Hirsch; M S Hussain; O Jansen; M V Jayaraman; A A Khalessi; B W Kluck; S Lavine; P M Meyers; S Ramee; D A Rüfenacht; C M Schirmer; D Vorwerk Journal: AJNR Am J Neuroradiol Date: 2018-05-17 Impact factor: 3.825
Authors: Juan F Arenillas; Elisa Cortijo; Pablo García-Bermejo; Elad I Levy; Reza Jahan; David Liebeskind; Mayank Goyal; Jeffrey L Saver; Gregory W Albers Journal: J Cereb Blood Flow Metab Date: 2017-11-14 Impact factor: 6.200
Authors: Mohammed Salman Shazeeb; Robert M King; Olivia W Brooks; Ajit S Puri; Nils Henninger; Johannes Boltze; Matthew J Gounis Journal: Transl Stroke Res Date: 2019-09-03 Impact factor: 6.829