By Matthew E. Fink, MD
Louis and Gertrude Feil Professor and Chair, Department of Neurology; Associate Dean for Clinical Affairs, NewYork Presbyterian/Weill Cornell Medical College
Dr. Fink reports no financial relationships relevant to this field of study.
SOURCE: Jahan R, Saver JL, Schwamm LH, et al. Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice. JAMA Neurol 2019;322:252-263.
Endovascular reperfusion therapy has been demonstrated to be of benefit for the treatment of large vessel occlusion in patients with acute ischemic stroke. This effect is time dependent and most of the randomized clinical trials enrolled patients who were no more than eight hours from onset of symptoms to puncture time. These investigators reviewed a real-life cohort of patients who had data recorded in the Get With The Guidelines–Stroke nationwide registry to determine if time to treatment had an effect on clinical outcomes. The database was explored for 6,756 patients with anterior circulation large vessel occlusion during the period January 2015 until December 2016. All patients had onset-to-puncture time of eight hours or less. Main outcomes were substantial reperfusion as determined by the thrombolysis in cerebral infarction (TICI) score of 2b-3, ambulatory status, global disability as determined by the modified Rankin scale, destination at discharge, symptomatic intracranial hemorrhage rate, and in-hospital mortality/hospice discharge. Mean age was 69.5 years, 51% of patients were women, and the median pretreatment score on the NIH stroke scale was 17. In addition, 85.9% of patients achieved substantial reperfusion. Adverse events were symptomatic intracerebral hemorrhage in 6.7% of patients and in-hospital mortality or hospice discharge in 19.6% of patients. At time of hospital discharge, 36.9% of patients were ambulating independently and 23% had functional independence as determined by a modified Rankin score of 0-2.
Overall, in the 30-270 minute time frame after onset of symptoms, faster onset-to-puncture time, in 15-minute increments, was associated with a higher likelihood of achieving independent function and discharge to home. In addition, faster onset to puncture also was associated with a lower in-hospital mortality or hospice discharge and a lower risk of symptomatic intracerebral hemorrhage.