Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

Man, Shumei; Solomon, Nicole; Grory, Brian Mac; Uchino, Ken; Saver, Jeffrey L.; Smith, Eric E.; Xian, Ying; Bhatt, Deepak L.; Schwamm, Lee H.; Hussain, Muhammad Shazam; Fonarow, Gregg C.

doi:10.1161/circulationaha.123.064053

Cited by 20 publications

(9 citation statements)

References 45 publications

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“…The Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke (HERMES) Collaborators found that the rates of good outcomes declined more rapidly in patients undergoing thrombectomy who received IVT than in patients ineligible for IVT, suggesting a potential differential effect of time. In addition, recent observational registry data from the US showed that shorter times from door to administration of IVT were associated with improved outcomes in patients undergoing thrombectomy …”

Section: Discussionmentioning

confidence: 99%

“…In addition, recent observational registry data from the US showed that shorter times from door to administration of IVT were associated with improved outcomes in patients undergoing thrombectomy. 7 After the publication of the HERMES results, 6,21 theoretical considerations for and against the use of IVT before thrombectomy were presented. 4,26 This equipoise was not only theoretical, but shared among treating physicians.…”

Section: Discussionmentioning

confidence: 99%

“…Certain subgroups of patients may benefit from a treatment strategy that combines IVT with thrombectomy, while other subgroups may not benefit or may experience harm from prior IVT . The time from stroke symptom onset to treatment is one potential factor that could influence the relative effectiveness and safety of administering IVT before thrombectomy …”

Section: Introductionmentioning

confidence: 99%

“…4,5 The time from stroke symptom onset to treatment is one potential factor that could influence the relative effectiveness and safety of administering IVT before thrombectomy. 6,7 This study aimed to determine whether the association of treatment with IVT plus thrombectomy vs thrombectomy alone and better outcomes was modified by the time from stroke symptom onset to treatment. Based on previous results and pathophysiological considerations, we hypothesized that there is a benefit associated with IVT plus thrombectomy if IVT is administered early after stroke symptom onset.…”

mentioning

confidence: 99%

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Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Kaesmacher,

Cavalcante,

Kappelhof

et al. 2024

JAMA

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ImportanceThe benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy.ObjectiveTo determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset.Design, Setting, and ParticipantsIndividual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313).ExposureInterval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone.Main Outcomes and MeasuresThe primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT.ResultsIn 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, −3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes.Conclusions and RelevanceIn patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Kaesmacher,

Cavalcante,

Kappelhof

et al. 2024

JAMA

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“…Intravenous thrombolysis (IVT) has been shown to improve outcomes in appropriately selected patients when administered within 4.5 hours of stroke onset . The benefits of thrombolysis are time dependent, and earlier treatment is associated with better outcomes . However, historically, only 20% to 30% of patients received thrombolysis within a door-to-needle (DTN) time of 60 minutes .…”

Section: Introductionmentioning

confidence: 99%

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Man,

Solomon,

Mac Grory

et al. 2024

JAMA Netw Open

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ImportanceUnderstanding is needed of racial and ethnic–specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.ObjectiveTo examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.Design, Setting, and ParticipantsThis retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines–Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.ExposuresTS phases I (2010-2013), II (2014-2018), and III (2019-2021).Main Outcomes and MeasuresThe primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.ResultsAnalyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.Conclusions and RelevanceIn this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

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Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

Kaźmierski

2023

J of Clinical Ultrasound

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To present the concept of a portable ultrasound tomography device for diagnosing traumatic and vascular brain lesions. The device consisting of multiple transcranial ultrasound probes placed on the surface of the head, specifically but not exclusively in natural acoustic windows. An integral part of the mobile diagnostic system (MDS) is a decision support system based on artificial intelligence algorithms utilizing information from: head images, laboratory data, and assessment of the patient's clinical condition. The MDS can significantly reduce the time from stroke onset to rtPA therapy in civilian medical services and support therapeutic and evacuation strategies in instances of brain and skull trauma on the battlefield.

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Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke

Cited by 20 publications

References 45 publications

Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Brain injury mobile diagnostic system: Applications in civilian medical service and on the battlefield—General concept and medical aspects

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