THIS is the whole problem with stroke leaders in a nutshell. They are accepting the status quo failure of tPA only fully working 12% of the time and not even suggesting any options of stopping the neuronal cascade of death. THIS IS WHY THEY ALL NEED TO BE FIRED.
First 4.5 Hours Crucial for Endovascular Tx
Faster treatment of greater importance during this window
Speedy endovascular therapy makes the
most difference in the first 4.5 hours after acute ischemic stroke
onset, a retrospective cohort study found.
With total onset-to-puncture times in the 30- to 270-minute window, every 15 minutes saved was associated with improvements in all clinical and adverse event outcomes:
"The magnitude of the time-benefit relation observed in this study, while requiring validation in an external data set, is clinically meaningful and emphasizes the importance of policies to accelerate treatment start," they concluded.
It also supported direct transfer of patients who likely have large vessel occlusion to thrombectomy-capable stroke centers, provided these hospitals are "only modestly more distant than primary stroke centers," they added.
Jahan's group studied the Get With The Guidelines-Stroke nationwide U.S. quality registry's 6,756 patients with documented anterior circulation large vessel occlusions treated by endovascular therapy within 8 hours.
Mean age was 69.5 years and roughly half of the cohort were women. People entered treatment with a median NIH Stroke Scale score of 17.
The median onset-to-puncture time was 230 minutes, and door-to-puncture time was 87 minutes. Half of patients had arrived by EMS transport, with a little less than half getting interhospital transfer.
Ultimately, rates of sICH and in-hospital mortality or hospice discharge were 6.7% and 19.6%, respectively.
Yet, 36.9% of patients walked independently and 23.0% had functional independence (modified Rankin Scale 0-2) at discharge.
These participants were treated in 2015-2016, a time period soon after the first positive thrombectomy trial was published and around when the FDA started clearing thrombectomy devices for use up to 8 hours after stroke onset.
"Accordingly, the onset-to-puncture criterion of 8 hours or less identified patients treated in accordance with prevailing regulatory and expert consensus guidance," Jahan and colleagues said.
They acknowledged that they were limited to the inherent accuracy and completeness of the available dataset. Moreover, they didn't know which patients might have had advanced physiological imaging.
Nevertheless, the study generally confirmed the generalizability of the time-benefit relationship previously established in clinical trials, maintained JAMA editor Christopher Muth, MD, of Rush University Medical Center in Chicago, in an editor's note.
"Future studies will need to consider broader time windows as the use of endovascular therapy expands beyond the time window evaluated in this study," he commented.
In the meantime, the question remains: When might many fast progressors be expected to reach large cores that limit excellent outcomes? That is the point to switch from a time-based to a tissue-based patient selection strategy and appears to begin as early as 240 to 270 minutes after last-known well time, according to the present study, Muth wrote.
Current guidelines have extended the thrombectomy window out to 24 hours.
With total onset-to-puncture times in the 30- to 270-minute window, every 15 minutes saved was associated with improvements in all clinical and adverse event outcomes:
- Independent ambulation was an absolute 1.14% more likely
- In-hospital mortality or hospice discharge was an absolute 0.77% less likely
- Symptomatic intracranial hemorrhage (sICH) showed an absolute 0.22% drop in risk
"The magnitude of the time-benefit relation observed in this study, while requiring validation in an external data set, is clinically meaningful and emphasizes the importance of policies to accelerate treatment start," they concluded.
It also supported direct transfer of patients who likely have large vessel occlusion to thrombectomy-capable stroke centers, provided these hospitals are "only modestly more distant than primary stroke centers," they added.
Jahan's group studied the Get With The Guidelines-Stroke nationwide U.S. quality registry's 6,756 patients with documented anterior circulation large vessel occlusions treated by endovascular therapy within 8 hours.
Mean age was 69.5 years and roughly half of the cohort were women. People entered treatment with a median NIH Stroke Scale score of 17.
The median onset-to-puncture time was 230 minutes, and door-to-puncture time was 87 minutes. Half of patients had arrived by EMS transport, with a little less than half getting interhospital transfer.
Ultimately, rates of sICH and in-hospital mortality or hospice discharge were 6.7% and 19.6%, respectively.
Yet, 36.9% of patients walked independently and 23.0% had functional independence (modified Rankin Scale 0-2) at discharge.
These participants were treated in 2015-2016, a time period soon after the first positive thrombectomy trial was published and around when the FDA started clearing thrombectomy devices for use up to 8 hours after stroke onset.
"Accordingly, the onset-to-puncture criterion of 8 hours or less identified patients treated in accordance with prevailing regulatory and expert consensus guidance," Jahan and colleagues said.
They acknowledged that they were limited to the inherent accuracy and completeness of the available dataset. Moreover, they didn't know which patients might have had advanced physiological imaging.
Nevertheless, the study generally confirmed the generalizability of the time-benefit relationship previously established in clinical trials, maintained JAMA editor Christopher Muth, MD, of Rush University Medical Center in Chicago, in an editor's note.
"Future studies will need to consider broader time windows as the use of endovascular therapy expands beyond the time window evaluated in this study," he commented.
In the meantime, the question remains: When might many fast progressors be expected to reach large cores that limit excellent outcomes? That is the point to switch from a time-based to a tissue-based patient selection strategy and appears to begin as early as 240 to 270 minutes after last-known well time, according to the present study, Muth wrote.
Current guidelines have extended the thrombectomy window out to 24 hours.
Jahan reported consulting for Medtronic Neurovascular, Balt USA, Blackswan Vascular, and Viz.ai.
Muth disclosed no conflicts.
Muth disclosed no conflicts.
Primary Source
JAMA
Source Reference: Jahan R, et al "Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice" JAMA 2019; DOI: 10.1001/jama.2019.8286.Secondary Source
JAMA
Source Reference: Muth CC "Endovascular therapy for acute ischemic stroke treated in clinical practice" JAMA 2019; 322(3): 263.
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