Impact of time between thrombolysis and endovascular thrombectomy on outcomes in patients with acute ischaemic stroke

 Bad research since it isn't even measuring 100% recovery.

Impact of time between thrombolysis and endovascular thrombectomy on outcomes in patients with acute ischaemic stroke

Lora Wagner¹, Desiree Mohrbach^1,2, Martin Ebinger^1,3, Matthias Endres^1,2,4,5,6, Christian H. Nolte^1,2,4, Peter Harmel^1,2, Heinrich J. Audebert^1,2, Jessica L. Rohmann^1,7*† and Bob Siegerink^1,8†

• ¹Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
• ²Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
• ³Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
• ⁴Berlin Institute of Health (BIH), Charité—Universitätsmedizin Berlin, Berlin, Germany
• ⁵German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
• ⁶German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
• ⁷Institute of Public Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
• ⁸Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, Netherlands

Background: Benefits of endovascular thrombectomy (ET) after intravenous thrombolysis (IVT) for patients with acute ischaemic stroke (AIS) have been demonstrated, but analyses of the relationship between IVT-ET time delay and functional outcomes among patients receiving both treatments are lacking.

Methods: We used data from the “Berlin—Specific Acute Treatment in Ischaemic and haemorrhAgic stroke with Long-term outcome” (B–SPATIAL) registry. Between January 1st, 2016 and December 31st, 2019, we included patients who received both IVT and ET. The primary outcome was the 3-month ordinal modified Rankin scale (mRS) score. The IVT-ET time delay was analyzed in categories and continuously. We used adjusted ordinal logistic regression to estimate common odds ratios (cOR) and 95% confidence intervals (CI). Secondary analyses involved flexible modeling of IVT-ET delay and dichotomous outcomes.

Results: Of 11,049 patients, 714 who received IVT followed by ET were included. Compared with having an IVT-ET window >120 min (reference), for an IVT-ET window < 30 min, we obtained adjusted cORs for mRS of 0.41 (95% CI: 0.22 to 0.78); and 0.52 (95% CI: 0.33 to 0.82) for 30 to 120 min. Secondary analyses also found protective effects of shorter time delays against “poor” functional outcomes at 3 months.

Conclusions: In patients with AIS, shorter IVT-ET intervals were associated with better 3-month functional outcomes.(But not good enough since you aren't even measuring 100% recovery. The only goal in stroke!) While the time-to-IVT and time-to-ET include the time until medical attention is received, the IVT-ET time delays fall entirely within the domain of medical management and thus might be easier to optimize.

Introduction

Acute ischaemic stroke (AIS) is one of the most common causes of morbidity and disability worldwide (1). There are two main acute treatment options for AIS, i.e., intravenous thrombolysis (IVT) and endovascular thrombectomy (ET) (2). In 2015, results from five randomized trials provided evidence for the superiority of ET, mostly in combination with IVT (“bridging thrombolysis”), compared to IVT alone (3–7). The benefits of IVT and ET combination therapy may be attributable to the ability of IVT to degrade remaining clot fragments, reduce ET procedure duration, and expedite recanalisation (8). Benefits of both recanalizing treatments, however, are known to diminish with increasing delay from symptom onset (or time last seen well) (9), hence, an earlier start of ET after IVT might result in more favorable outcomes for AIS patients.

Although “time–to–treatment” is a generally well-researched topic in stroke (10, 11), typically measured as the time of symptom onset to treatment initiation, the potential impact of the specific time delay between IVT and ET has not been well studied.

We aimed to estimate the effect of the time delay between IVT and ET on functional outcome as measured by the modified Rankin Scale (mRS) score 90 days after stroke among AIS patients who received both IVT and ET using prospectively-collected data from a large stroke registry in Berlin, Germany.

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