Jahan R, Saver J, Schwamm L, Fonarow G, Liang L, Matsouaka R, Xian Y, Holmes D, Peterson E, Yavagal D, Smith E.

JAMA. 2019;322(3):252–263. doi:10.1001/jama.2019.8286.

2019

Hospital

Hospital (HAP)

Not applicable

No

To characterize the association of speed of treatment with outcome among patients with acute ischemic stroke (AIS) undergoing endovascular-reperfusion therapy.

Cohort Study

Retrospective cohort study used data from The Guidelines-Stroke nationwide US quality registry. Analysis was conducted using data regarding patients treated between January 1, 2015, and December31, 2016, with final follow-up through April 15, 2017. Participants were 6756 patients with anterior circulation large vessel occlusion AIS treated with endovascular-reperfusion therapy with onset-to-puncture time of 8 hours or less. Main outcomes and 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.

Among 6756 patients, the mean (SD) age was 69.5 (14.8) years, 51.2%(3460/6756) were women, and median pretreatment score on the National Institutes of Health Stroke Scale was 17 (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%(5433/6324) of patients. Adverse events were sICH in 6.7% (449/6693) of patients and in-hospital mortality/hospice discharge in 19.6%(1326/6756) of patients. At discharge, 36.9% (2132/5783) ambulated independently and 23.0%(1225/5334) had functional independence (mRS 0-2). In onset-to-puncture adjusted analysis, time-outcome relationships were nonlinear with steeper slopes between 30 to 270 minutes than 271 to 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%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.

2015-2016

acute ischemic stroke (AIS), endovascular-reperfusion therapy

Positive