Stroke Rounds: Earlier Perfusion Better With Stent Retrievers

Yet still there is absolutely NO talk about stopping the neuronal cascade of death. IS EVERYONE IN STROKE COMPLETELY FUCKING STUPID? Haven't read any research at all?
http://www.medpagetoday.com/Cardiology/Strokes/55360?xid=nl_mpt_cardiodaily_2015-12-21& 
Every hour of delay in restoring blood flow during acute ischemic stroke treatment was associated with a lower chance of benefiting from intra-arterial thrombolysis, a MR CLEAN substudy found.
How long it took to achieve reperfusion after starting treatment was associated with magnitude of advantage over usual care for functional independence by 90 days as denoted by a modified Rankin Scale (mRS) score of 2 or lower (P=0.04), Diederik W. J. Dippel, MD, PhD, of Erasmus MC University Medical Center Rotterdam in The Netherlands, and colleagues found.
On the other hand, each hour of reperfusion delay cut the the absolute advantage of intra-arterial treatment (largely endovascular thrombectomy in the trial) for functional independence by 6.4%, the group reported online in JAMA Neurology, similar to their initial report at the 2015 International Stroke Conference.
For clinicians, "our findings imply that patients with acute ischemic stroke should undergo an immediate diagnostic workup and intra-arterial treatment in case of intracranial arterial vessel occlusion," they concluded.
Dippel's study is the "strongest statement" thus far about the "benefit of early reperfusion," commented Joseph P. Broderick, MD, of the University of Cincinnati Medical Center, who was not involved with the study.
"Minimizing delay to reperfusion in eligible patients has a major benefit in outcome. This replicates what is found with IV t-PA in terms of greatest benefit found in those treated most quickly after onset," he added.
In order to ensure a quick route to reperfusion, efficient logistics will be key every step of the way, Broderick suggested to MedPage Today in an email. That includes efficiency in "the prehospital setting, in the emergency department, [and] in early activation of the interventional team," he said. Furthermore, clinicians should use a "focused approach" when dealing with an occluded artery.
Dippel's group hypothesized that delayed reperfusion is more likely to be attributable "to patient transportation" rather than "procedure difficulty or later presentation to medical attention."
Time from stroke onset to groin puncture had no relationship with functional independence conferred by thrombolysis (P=0.26) in the study. Thus, time from symptom onset to reperfusion "might be a better indicator" than time to groin puncture, according to the authors.
Guidelines call for use of mechanical thrombectomy only when groin puncture is feasible within 6 hours of symptom onset for selected patients.
The multi-center MR CLEAN trial randomized 500 severe stroke patients with proximal large-vessel occlusion treated up to 6 hours after stroke onset to receive intra-arterial thrombolysis -- a treatment consisting of mechanical thrombectomy, thrombolytic agent, or both -- in addition to usual care or usual care alone.
While followed by other positive clinical trials like ESCAPE, EXTEND-IA, and SWIFT PRIME, MR CLEAN was the first to demonstrate that mechanical thrombectomy improved outcomes, such as disability and survival, compared to medical treatment alone.
The substudy showed that the large treatment effect observed in recipients of early reperfusion (adjusted common odds ratio 2.28, 95% confidence interval 1.28-4.06) noticeably dwindled in size for their later counterparts (adjusted common OR 1.13, 95% CI 0.64-2.01). Successful reperfusion was defined as reaching a modified Thrombolysis in Cerebral Infarction score of 2b or 3.
Similarly, the investigators found that the absolute risk difference for a favorable mRS score had an inverse association with reperfusion delay:

• 3 hours after stroke onset, the absolute risk difference was 25.9% (95% CI 8.3%-44.4%)
• After 4 hours, the absolute risk difference fell to 18.8% (95% CI 6.6%-32.6%)
• After 6 hours, it dropped to 6.7% (95% CI 0.4%-14.5%)

"The largest treatment effect was observed if reperfusion was achieved early after the onset of symptoms," Dippel and colleagues wrote. They warn, however, that their study "allows conclusions" only in a 6-hour time frame, noting that their results "do not provide arguments for withholding treatment from patients" beyond that time window.
"This study highlights the critical importance of reducing delays in time to intra-arterial treatment for patients with acute ischemic stroke. The absolute treatment effect and its decrease over time are larger than those reported for intravenous treatment," they concluded.