Bijoy K Menon1, Tolulope T Sajobi1, Yukun Zhang1, Jeremy L Rempel1, Ashfaq Shuaib1, John Thornton1, David Williams1, Daniel Roy1, Alexandre Y Poppe1, Tudor G Jovin1, Biggya Sapkota1, Blaise W Baxter1, Timo Krings1, Frank L Silver1, Donald F Frei1, Christopher Fanale1, Donatella Tampieri1, Jeanne Teitelbaum1, Cheemun Lum1, Dar Dowlatshahi1, Muneer Eesa1, Mark W Lowerison1, Noreen R Kamal1, Andrew M Demchuk1, Michael D Hill1, Mayank Goyal2. 1. From Department of Clinical Neurosciences and Radiology (B.K.M., T.T.S., M.E., N.R.K., A.M.D, M.D.H., M.G.) andDepartment of Community Health Sciences (B.K.M., Y.Z., A.M.D.,M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Canada; Departments of Radiology (J.L.R.) and Medicine (A.S.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J.T.) andGeriatric and Stroke Medicine(D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), University of Montreal, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services, University of Tennessee, Chattanooga (B.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology (T.K.) andDivision of Neurology, Department of Medicine (F.L.S.), Toronto Western Hospital, Canada; Colorado Neurological Institute, Engelwood, CO (D.F.F., C.F.); Montreal Neurological Institute, Canada (D.T., J.T.); Departments of Radiology (C.L.) and Neurology (D.D.), University of Ottawa, Canada; Clinical Research Unit, University of Calgary, Canada (M.W.L.); and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., T.T.S., M.E., A.M.D., M.D.H., M.G.). 2. From Department of Clinical Neurosciences and Radiology (B.K.M., T.T.S., M.E., N.R.K., A.M.D, M.D.H., M.G.) andDepartment of Community Health Sciences (B.K.M., Y.Z., A.M.D.,M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Canada; Departments of Radiology (J.L.R.) and Medicine (A.S.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J.T.) andGeriatric and Stroke Medicine(D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), University of Montreal, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services, University of Tennessee, Chattanooga (B.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology (T.K.) andDivision of Neurology, Department of Medicine (F.L.S.), Toronto Western Hospital, Canada; Colorado Neurological Institute, Engelwood, CO (D.F.F., C.F.); Montreal Neurological Institute, Canada (D.T., J.T.); Departments of Radiology (C.L.) and Neurology (D.D.), University of Ottawa, Canada; Clinical Research Unit, University of Calgary, Canada (M.W.L.); and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., T.T.S., M.E., A.M.D., M.D.H., M.G.). mgoyal@ucalgary.ca.
Abstract
BACKGROUND: The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital, and health system characteristics on workflow within the trial. METHODS AND RESULTS:Relationship between outcome (modified Rankin Scale) and interval times was modeled by using logistic regression. Association between time intervals (stroke onset to arrival in endovascular-capable hospital, to qualifying computed tomography, to groin puncture, and to reperfusion) and patient, hospital, and health system characteristics were modeled by using negative binomial regression. Every 30-minute increase in computed tomography-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90-day modified Rankin Scale 0-2) by 8.3% (P=0.006). Symptom onset-to-imaging time was not associated with outcome (P>0.05). Onset-to-endovascular hospital arrival time was 42% (34 minutes) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) versus direct transfer (mothership). Computed tomography-to-groin puncture time was 15% (8 minutes) shorter among patients presenting during work hours versus off hours, 41% (24 minutes) shorter in drip-ship patients versus mothership, and 43% (22 minutes) longer when general anesthesia was administered. The use of a balloon guide catheter during endovascular procedures shortened puncture-to-reperfusion time by 21% (8 minutes). CONCLUSIONS: Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, use of general anesthesia, and endovascular techniques offer major opportunities for improvement in workflow. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.
RCT Entities:
BACKGROUND: The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital, and health system characteristics on workflow within the trial. METHODS AND RESULTS: Relationship between outcome (modified Rankin Scale) and interval times was modeled by using logistic regression. Association between time intervals (stroke onset to arrival in endovascular-capable hospital, to qualifying computed tomography, to groin puncture, and to reperfusion) and patient, hospital, and health system characteristics were modeled by using negative binomial regression. Every 30-minute increase in computed tomography-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90-day modified Rankin Scale 0-2) by 8.3% (P=0.006). Symptom onset-to-imaging time was not associated with outcome (P>0.05). Onset-to-endovascular hospital arrival time was 42% (34 minutes) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) versus direct transfer (mothership). Computed tomography-to-groin puncture time was 15% (8 minutes) shorter among patients presenting during work hours versus off hours, 41% (24 minutes) shorter in drip-ship patients versus mothership, and 43% (22 minutes) longer when general anesthesia was administered. The use of a balloon guide catheter during endovascular procedures shortened puncture-to-reperfusion time by 21% (8 minutes). CONCLUSIONS: Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, use of general anesthesia, and endovascular techniques offer major opportunities for improvement in workflow. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.
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: Mayank Goyal; Mohammed A Almekhlafi; Christoph Cognard; Ryan McTaggart; Kristine Blackham; Alessandra Biondi; Aad van der Lugt; Charles B L M Majoie; Wim H van Zwam; H Bart van der Worp; Michael D Hill Journal: Neuroradiology Date: 2019-01 Impact factor: 2.804
Authors: Jessalyn K Holodinsky; Tyler S Williamson; Andrew M Demchuk; Henry Zhao; Luke Zhu; Michael J Francis; Mayank Goyal; Michael D Hill; Noreen Kamal Journal: JAMA Neurol Date: 2018-12-01 Impact factor: 18.302