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JAMA. 2016 Sep 27;316(12):1279-88. doi: 10.1001/jama.2016.13647.

Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis.

Author information

1
David Geffen School of Medicine, University of California-Los Angeles, Los Angeles.
2
University of Calgary, Calgary, Alberta, Canada.
3
Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
4
Academic Medical Center, Amsterdam, the Netherlands.
5
University of Melbourne, Melbourne, Australia.
6
Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.
7
Hospital Vall d'Hebron, Barcelona, Spain.
8
Hospital de Bellvitge, L'Hospet de Llobregat, Barcelona, Spain.
9
Erlanger Hospital at the University of Tennessee, Chattanooga.
10
Swedish Medical Center, Englewood, Colorado.
11
Klinikum der Goethe-Universität, Frankfurt, Germany.
12
University of Pittsburgh Medical Center, Pittsburgh, Pennyslvania.
13
State University of New York at Buffalo, Buffalo.
14
Maastricht University Medical Center, Maastricht, the Netherlands.
15
Hospital Germans Trias i Pujol, Barcelona, Spain.
16
Erlanger Medical Center, Chattanooga, Tennessee.
17
Hospital Clinic de Barcelona, Barcelona, Spain.
18
University Health Network, Toronto, Ontario, Canada.
19
Florey Institute, Melbourne, Australia.
20
University of Alberta, Edmonton, Alberta, Canada.
21
Altair Biostatistics, St Louis Park, Minnesota.
22
Philadelphia College of Osteopathic Medicine, Philadelphia, Pennyslvania.

Abstract

IMPORTANCE:

Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Delineation of the association of treatment time with outcomes would help to guide implementation.

OBJECTIVE:

To characterize the period in which endovascular thrombectomy is associated with benefit, and the extent to which treatment delay is related to functional outcomes, mortality, and symptomatic intracranial hemorrhage.

DESIGN, SETTING, AND PATIENTS:

Demographic, clinical, and brain imaging data as well as functional and radiologic outcomes were pooled from randomized phase 3 trials involving stent retrievers or other second-generation devices in a peer-reviewed publication (by July 1, 2016). The identified 5 trials enrolled patients at 89 international sites.

EXPOSURES:

Endovascular thrombectomy plus medical therapy vs medical therapy alone; time to treatment.

MAIN OUTCOMES AND MEASURES:

The primary outcome was degree of disability (mRS range, 0-6; lower scores indicating less disability) at 3 months, analyzed with the common odds ratio (cOR) to detect ordinal shift in the distribution of disability over the range of the mRS; secondary outcomes included functional independence at 3 months, mortality by 3 months, and symptomatic hemorrhagic transformation.

RESULTS:

Among all 1287 patients (endovascular thrombectomy + medical therapy [n = 634]; medical therapy alone [n = 653]) enrolled in the 5 trials (mean age, 66.5 years [SD, 13.1]; women, 47.0%), time from symptom onset to randomization was 196 minutes (IQR, 142 to 267). Among the endovascular group, symptom onset to arterial puncture was 238 minutes (IQR, 180 to 302) and symptom onset to reperfusion was 286 minutes (IQR, 215 to 363). At 90 days, the mean mRS score was 2.9 (95% CI, 2.7 to 3.1) in the endovascular group and 3.6 (95% CI, 3.5 to 3.8) in the medical therapy group. The odds of better disability outcomes at 90 days (mRS scale distribution) with the endovascular group declined with longer time from symptom onset to arterial puncture: cOR at 3 hours, 2.79 (95% CI, 1.96 to 3.98), absolute risk difference (ARD) for lower disability scores, 39.2%; cOR at 6 hours, 1.98 (95% CI, 1.30 to 3.00), ARD, 30.2%; cOR at 8 hours,1.57 (95% CI, 0.86 to 2.88), ARD, 15.7%; retaining statistical significance through 7 hours and 18 minutes. Among 390 patients who achieved substantial reperfusion with endovascular thrombectomy, each 1-hour delay to reperfusion was associated with a less favorable degree of disability (cOR, 0.84 [95% CI, 0.76 to 0.93]; ARD, -6.7%) and less functional independence (OR, 0.81 [95% CI, 0.71 to 0.92], ARD, -5.2% [95% CI, -8.3% to -2.1%]), but no change in mortality (OR, 1.12 [95% CI, 0.93 to 1.34]; ARD, 1.5% [95% CI, -0.9% to 4.2%]).

CONCLUSIONS AND RELEVANCE:

In this individual patient data meta-analysis of patients with large-vessel ischemic stroke, earlier treatment with endovascular thrombectomy + medical therapy compared with medical therapy alone was associated with lower degrees of disability at 3 months. Benefit became nonsignificant after 7.3 hours.

PMID:
27673305
DOI:
10.1001/jama.2016.13647
[Indexed for MEDLINE]
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