Impact of onset-to-groin puncture time within three hours on functional outcomes in mechanical thrombectomy for acute large-vessel occlusion

Abstract

Introduction

Endovascular treatment for acute ischemic stroke with acute large-vessel occlusion (ALVO) has established benefits, and rapid treatment is vital for mechanical thrombectomy in ALVO. Time from onset of stroke to groin puncture (OTP) is a practical and useful clinical marker, and OTP should be shortened to obtain the maximum benefit of thrombectomy.

Objective

The aim of the present study was to assess the impact of early treatment of anterior circulation stroke within three hours after symptom onset and to evaluate the role of OTP in determining outcomes after endovascular therapy.

Methods

Consecutive patients with acute stroke due to major artery (internal carotid or middle cerebral arteries) occlusion who underwent endovascular recanalization between March 2014 and January 2017 were retrospectively evaluated. Patients were stratified by OTP into three categories: 0–≤3 h, >3–≤6 h, and >6 h. The primary outcome measure was a 90-day modified Rankin scale score of 0–2 (good outcome).

Results

Data were analyzed from 100 patients (mean age, 76.6 years; mean National Institutes of Health Stroke Scale score, 17). Groin puncture occurred within 0–≤3 h in 51 patients, >3–≤6 h in 28, and >6 h in 21. Median OTP in each group was 126 min (range, 57–168 min), 238 min (range, 186–360 min) and 728 min (range, 365–1492 min), respectively. On multivariable logistic regression analysis, category of OTP represented an independent predictor of patient outcome (adjusted odds ratio, 0.48; 95% confidence interval, 0.25–0.93; p = 0.029).

Conclusions

OTP is a prehospital and in-hospital workflow-based indicator. In this single-center study, OTP was found to independently affect functional outcomes after endovascular stroke treatment.

Keywords

Mechanical thrombectomy onset-to-groin puncture time target time

Get full access to this article

View all access options for this article.

References

Berkhemer

Fransen

Beumer

et al.

A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11–20.

Saver

Goyal

Bonafé

et al.

Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372: 2285–2295.

Campbell

Mitchell

Kleinig

et al.

Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 1009–1018.

Goyal

Demchuk

Menon

et al.

Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019–1030.

Khatri

Yeatts

Mazighi

et al.

Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: An analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol 2014; 13: 567–574.

Mazighi

Chaudhry

Ribo

et al.

Impact of onset-to-reperfusion time on stroke mortality: A collaborative pooled analysis. Circulation 2013; 127: 1980–1985.

Menon

Sajobi

Zhang

et al.

Analysis of workflow and time to treatment on thrombectomy outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) randomized, controlled trial. Circulation 2016; 133: 2279–2286.

Fransen

Berkhemer

Lingsma

et al.

Time to reperfusion and treatment effect for acute ischemic stroke: A randomized clinical trial. JAMA Neurol 2016; 73: 190–196.

Prabhakaran

Castonguay

Gupta

et al.

Complete reperfusion mitigates influence of treatment time on outcomes after acute stroke. J Neurointerv Surg 2017; 9: 366–369.

10.

Jayaraman

Hussain

Abruzzo

et al.

Embolectomy for stroke with emergent large vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery. J Neurointerv Surg 2015; 7: 316–321.

11.

Haršány

Kadlecová

Švigelj

et al.

Factors influencing door-to-imaging time: Analysis of the safe implementation of treatments in Stroke-EAST registry. J Stroke Cerebrovasc Dis 2014; 23: 2122–2129.

12.

Ribo

Molina

Cobo

et al.

Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke 2016; 47: 999–1004.

13.

Sun

Nogueira

Glenn

et al.

“Picture to puncture”: A novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke. Circulation 2013; 127: 1139–1148.

14.

Mehta

Leslie-Mazwi

Chandra

et al.

Reducing door-to-puncture times for intra-arterial stroke therapy: A pilot quality improvement project. J Am Heart Assoc 2014; 3: e000963.

15.

Powers

Derdeyn

Biller

et al.

2015 American Heart Association/American Stroke Association focused update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46: 3020–3035.

16.

Nezu

Koga

Kimura

et al.

Pretreatment ASPECTS on DWI predicts 3-month outcome following rt-PA: SAMURAI rt-PA Registry. Neurology 2010; 75: 555–561.

17.

Adams

Jr Bendixen

Kappelle

et al.

Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24: 35–41.

18.

Bush

Kurimella

Cross

et al.

Endovascular treatment with stent-retriever devices for acute ischemic stroke: A meta-analysis of randomized controlled trials. PLoS One 2016; 11: e0147287.

19.

Lodi

Reddy

Petro

et al.

Primary acute stroke thrombectomy within 3 h for large artery occlusion (PAST3-LAO): A pilot study. J Neurointerv Surg 2017; 9: 352–356.

20.

Almekhlafi

Davalos

Bonafé

et al.

Impact of age and baseline NIHSS scores on clinical outcomes in the mechanical thrombectomy using Solitaire FR in acute ischemic stroke study. AJNR Am J Neuroradiol 2014; 35: 1337–1340.

21.

Goyal

Jadhav

Bonafé

et al.

Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: Results from the SWIFT PRIME randomized controlled trial. Radiology 2016; 279: 888–897.

22.

Aghaebrahim

Streib

Rangaraju

et al.

Streamlining door to recanalization processes in endovascular stroke therapy. J Neurointerv Surg 2017; 9: 340–345.

23.

Mehta

Leslie-Mazwi

Chandra

et al.

Assessing variability in neurointerventional practice patterns for acute ischemic stroke. J Neurointerv Surg 2013; 5(Suppl 1): i52–i57.

24.

Menon

Almekhlafi

Pereira

et al.

Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: Analysis of the Solitaire FR Thrombectomy for Acute Revascularization study. Stroke 2014; 45: 2024–2029.

25.

Gupta

Horev

Nguyen

et al.

Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes. J Neurointerv Surg 2013; 5: 294–297.

26.

Jadhav

Kenmuir

Aghaebrahim

et al.

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy. Stroke 2017; 48: 1884–1889.

27.

Terasawa

Kimura

Iguchi

et al.

Could clinical diffusion-mismatch determined using DWI ASPECTS predict neurological improvement after thrombolysis before 3 h after acute stroke?

J Neurol Neurosurg Psychiatry 2010; 81: 864–868.