Time to Endovascular Reperfusion and Degree of Disability in Acute Stroke

• Type of Material: Article
• Authors: Sunil A. Sheth, University of California Los Angeles; Reza Jahan, University of California Los Angeles; Jan Gralla, University of Bern; Vitor M. Pereira, University of Toronto; Raul Nogueira, Emory University; Elad I. Levy, University at Buffalo; Osama O. Zaidat, Medical College of Wisconsin; Jeffrey L. Saver, University of California Los Angeles
• Language: English
• Date: 2015-10-01
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2015 American Neurological Association.
• Final Published Version (URL): http://dx.doi.org/10.1002/ana.24474
• Title of Journal or Parent Work: Annals of Neurology
• ISSN: 0364-5134
• Volume: 78
• Issue: 4
• Start Page: 584
• End Page: 593
• Keywords: Neurosciences; Neurosciences & Neurology; Clinical Neurology; TISSUE-PLASMINOGEN ACTIVATOR; THROMBECTOMY; REVASCULARIZATION; Life Sciences & Biomedicine; RANDOMIZED-TRIAL; ACUTE ISCHEMIC-STROKE; TREAT; OUTCOMES
• Research Categories: Health Sciences, Medicine and Surgery; Biology, Neuroscience

Abstract

Objective: Faster time from onset to recanalization (OTR) in acute ischemic stroke using endovascular therapy (ET) has been associated with better outcome. However, previous studies were based on less-effective first-generation devices, and analyzed only dichotomized disability outcomes, which may underestimate the full effect of treatment. Methods: In the combined databases of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever with achievement of substantial reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b–3). Ordinal numbers needed to treat values were derived by populating joint outcome tables. Results: Among 202 patients treated with ET with TICI 2b to 3 reperfusion, mean age was 68 (±13), 62% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range [IQR]: 14– 20). Day 90 modified Rankin Scale (mRS) outcomes for OTR time intervals ranging from 180 to 480 minutes showed substantial time-related reductions in disability across the entire outcome range. Shorter OTR was associated with improved mean 90-day mRS (1.4 vs. 2.4 vs. 3.3, for OTR groups of 124–240 vs. 241–360 vs. 361–660 minutes; p < 0.001). The number of patients identified as benefitting from therapy with shorter OTR were 3-fold (range, 1.5–4.7) higher on ordinal, compared with dichotomized analysis. For every 15-minute acceleration of OTR, 34 per 1,000 treated patients had improved disability outcome. Interpretation: Analysis of disability over the entire outcome range demonstrates a marked effect of shorter time to reperfusion upon improved clinical outcome, substantially higher than binary metrics. For every 5-minute delay in endovascular reperfusion, 1 of 100 patients has a worse disability outcome.