Impact of Onset-to-Reperfusion Time on Stroke Mortality

Abstract

Background-Onset-to-reperfusion time has been reported to be associated with clinical prognosis. However, its impact on mortality remained to be assessed. Using a collaborative pooled analysis, we examined whether early mortality after successful endovascular treatment is time dependent. Methods and Results-In a collaborative pooled analysis of 7 endovascular databases, we assessed the impact of onsetto-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes. Successful reperfusion was defined as complete or partial restoration of blood flow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modified Rankin Scale score, 0-2), 90-day excellent outcome (modified Rankin Scale score, 0-1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. A total of 480 cases with successful reperfusion (median time, 285 minutes) contributed to the present pooled analysis (120 with internal carotid artery occlusion and 360 with isolated middle cerebral artery occlusion). Increasing onset-to-reperfusion time was associated with an increased rate of mortality and intracerebral hemorrhage and with a decreased rate of favorable and excellent outcomes, without heterogeneity across studies. The adjusted odds ratio for each 30-minute time increase was 1.21 (95% confidence interval, 1.09-1.34; P<0.001) for mortality, 0.79 (95% confidence interval, 0.72-0.87) for favorable outcome, 0.78 (95% confidence interval, 0.71-0.86) for excellent outcome, and 1.21 (95% confidence interval, 1.10-1.33) for intracerebral hemorrhage. Conclusion-Onset-to-reperfusion time affects mortality and favorable outcome and should be considered the main goal in acute stroke patient management. (Circulation. 2013;127:1980-1985 13 A pooled analysis of the 2 IMS trials 3 and a single-center experience study 2 have previously reported the impact of ORT on good clinical outcome, but none has studied associations with 90-day mortality. The methodologies (study period, treatment specificities, baseline characteristics, and outcomes) of the 7 studies are summarized in Table 1. Eligibility, Data Collection, and DefinitionsPatients were eligible for inclusion in this study if they (1) had a largeartery occlusion (intracranial internal carotid artery or middle cerebral artery, M1 or M2) treated by an endovascular approach (thrombolysis or mechanical endovascular therapy) with or without prior use of intravenous thrombolysis; (2) had a successful angiographic reperfusion within 8 hours from symptom onset, defined as a complete or partial restoration of blood flow (Thrombolysis in Myocardial Infarction grade 2-3) 14 ; and (3) had available information on vital status. Data from individual patients were collected on a standardized form with predefined variables and were compiled and analyzed at the coordinating center (University Bichat Hospital, Paris). The following variables were collected: age; sex; initia...

Impact of Time-to-Reperfusion on Outcome in Patients with Poor Collaterals

“…[5][6][7][8][9][10][11] Also, the ORT in intra-arterial treatment was a main determinant factor in predicting favorable outcome. 3,4 Regarding collateral flow and ORT as determinant factors of favorable outcome, reperfusion of Ͼ300 minutes from onset in a poor collateral group was associated with decreased odds of clinical improvement and favorable outcome from a small retrospective cohort. 27 Our study also showed that ORT is a critical determinant of favorable outcome in a time-dependent fashion (each minute, 30 minutes, or reperfusion of Ͼ300 minutes were all associated with a decreased chance of favorable outcome).…”

“…and neuroradiologist (D.-H.K.) blinded to patient information and was dichotomized as poor (collateral-flow grades 0 -1) and good (2)(3)(4). 19 The coefficient for interobserver agreement was 0.864 for each collateral grade.…”

“…1,2 Also, the effect of reperfusion on outcome is time-dependent, and onset-to-reperfusion time (ORT) has emerged as an important time metric to show the benefit of endovascular treatment. 3,4 However, the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. [5][6][7][8][9][10][11] Baseline collateral flow, which is an important determinant of clinical recovery, can mitigate potential injury to ischemic brain tissue.…”

Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

“…This result was consistent with the findings of a previous study, which revealed an association between the time from onset to revascularization and a favorable clinical outcome and survival. 18 Given that no significant differences in the time from puncture to revascularization was identified between the groups, minimizing delays between stroke onset and hospital admission is a key factor for achieving good clinical outcomes.…”

Mechanical Thrombectomy for Acute Intracranial Internal Carotid Artery Occlusion Compared with Middle Cerebral Artery Occlusion

“…In general, a 30-min delay in the time until recanalization increases the incidence of early intracranial bleeding and mortality rate, and leads to poor outcomes. 21,22) Since the progression of neurological deficits may be rapid particularly in patients with ICO as described above, further shortening of the time is necessary. In this study, the procedure time was about 60 min, and the success rate using only the device as the first choice was about 50%.…”