title: Effect of time to reperfusion on clinical outcome of anterior circulation strokes treated with thrombectomy: pooled analysis of the MERCI and Multi MERCI trials.
abstract: OBJECTIVE
  Previous studies have demonstrated a strong correlation between treatment time and outcomes after intravenous recombinant tissue-type plasminogen activator. However, the temporal profile of ischemia may vary according to the level of occlusion, and it is likely that more proximal occlusions have a more variable temporal course than their distal counterparts. We sought to establish how time influences outcomes in anterior circulation proximal arterial occlusions.
  
  
  METHODS
  All patients from the MERCI/Multi MERCI trials with intracranial internal carotid artery and/or middle cerebral artery (M1-M2 segments) occlusions who were successfully revascularized were included in univariate/multivariate analyses to define the predictors of independent functional outcomes (modified Rankin Scale score ≤2) and mortality at 90 days. The effect of time to reperfusion on outcomes was calculated after adjustment for age, baseline National Institutes of Health Stroke Scale, and glucose levels.
  
  
  RESULTS
  A total of 175 patients presenting with internal carotid artery/M1/M2 occlusions were revascularized. There was no definite association between time (to treatment or reperfusion) and outcomes in the unadjusted analysis. Baseline National Institutes of Health Stroke Scale score and age were independent predictors of independent outcome and mortality. High glucose demonstrated a strong trend toward worse outcomes. After adjustment for age, baseline National Institutes of Health Stroke Scale score, and glucose, there was a strong trend toward fewer independent outcomes with later reperfusion times. Notably, 40% of the patients reperfused at ≥6.9 hours achieved independent functional outcomes.
  
  
  CONCLUSIONS
  Time (to treatment or reperfusion) is only one of the many variables that may impact outcome in proximal arterial occlusions strokes. Reperfusion therapies should be started promptly, but our findings also suggest that stroke patients presenting at later time points may still benefit.
authors.affiliation: Department of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA. rnoguei@emory.edu
authors.forename: Raul G
authors.initials: RG
authors.lastname: Nogueira
authors.forename: Wade S
authors.initials: WS
authors.lastname: Smith
authors.forename: Gene
authors.initials: G
authors.lastname: Sung
authors.forename: Gary
authors.initials: G
authors.lastname: Duckwiler
authors.forename: Gary
authors.initials: G
authors.lastname: Walker
authors.forename: Robin
authors.initials: R
authors.lastname: Roberts
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.forename: David S
authors.initials: DS
authors.lastname: Liebeskind
mesh_terms: D000368:Aged; D002548:Cerebral Revascularization / Q000379:methods*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015424:Reperfusion / Q000379:methods; D020521:Stroke / Q000503:physiopathology* / Q000601:surgery*; D017131:Thrombectomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome