This Is How Much Every Second Counts in Stroke Thrombectomy

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This Is How Much Every Second Counts in Stroke Thrombectomy

Delays until reperfusion cost years of healthy life, meta-analysis suggests

by Nicole Lou, Staff Writer, MedPage Today May 3, 2021

Every delay in endovascular thrombectomy (EVT) translated into life lost after stroke, according to a patient-level meta-analysis that underscored the importance of fast reperfusion.

For stroke patients receiving EVT early (i.e., with last known well-to-puncture [LKWTP] times within 4 hours) who had substantial reperfusion, times to puncture and reperfusion were indicators of subsequent clinical outcome, reported Mohammed Almekhlafi, MD, MSc, of the University of Calgary in Alberta, Canada, and colleagues of the HERMES group.

For example, every hour of delay in LKWTP was tied to a loss of 0.81 healthy life-years, a "substantial" number that translates to "1.6 months per 10-minute delay, 4.9 days per 1-minute delay, and 2.0 hours per 1-second delay," the group wrote in JAMA Neurology.

Similarly, each second of delay in door-to-puncture (DTP) time and door-to-reperfusion (DTR) time amounted to 2.2 hours and 2.4 hours of healthy life lost, respectively. However, symptom onset-to-door times had no statistically significant time-benefit association.

"Delays, particularly after arrival to the hospital until reperfusion is achieved, may result in substantial losses in years of healthy life for patients. Efforts to optimize workflow and eliminate barriers preventing timely patient evaluation and treatment within health care systems are warranted," the authors concluded.

It has long been established that "time is brain" in stroke thrombectomy. Efforts are ongoing to shorten door-to-intervention times worldwide, with the American Heart Association and American Stroke Association recommending certain workflow targets to accelerate care delivery.

Almekhlafi and colleagues performed a meta-analysis of seven randomized trials testing EVT within 12 hours of acute ischemic stroke onset due to large vessel occlusion. They rated disability according to the utility-weighted modified Rankin Scale score, and based age-specific life expectancies on the 2017 U.S. National Vital Statistics.

The HERMES collaboration allowed investigators to gather patient-level data on participants for their study. There were 781 EVT-treated patients, of whom 52% had early thrombectomy and the rest had late thrombectomy with LKWTP times of 4-12 hours.

The early group had a median LKWTP time of 188 minutes and DTP time of 105 minutes. Of the 78.4% who had successful reperfusion in this cohort, it was achieved after a median last known well-to-reperfusion time of 234 minutes and DTR time of 145 minutes.

An explanatory analysis of the late-treated population -- a cohort more likely to have strokes with unwitnessed onset and symptoms first observed on awakening, but fewer patients with fast progression -- showed no significant relationship between times to puncture (or reperfusion) and life lost.

Heterogeneous entry criteria and imaging methods across trials were study limitations, Almekhlafi's group acknowledged. Findings also may not be generalizable to patients with pre-existing disability or those treated after 12 hours, two groups that were not included in the seven trials of the meta-analysis.

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  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

The study was funded by a grant from Medtronic to the University of Calgary HERMES Coordinating Center.

Almekhlafi is a member of the scientific advisory board of Palmera Medical.

Primary Source

JAMA Neurology

Source Reference: Almekhlafi MA, et al "Healthy life-year costs of treatment speed from arrival to endovascular thrombectomy in patients with ischemic stroke: a meta-analysis of individual patient data from 7 randomized clinical trials" JAMA Neurol 2021; DOI: 10.1001/jamaneurol.2021.1055.