Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial.
BACKGROUND
The IMS III trial did not show a clinical benefit of endovascular treatment compared with intravenous alteplase (recombinant tissue plasminogen activator) alone for moderate or severe ischaemic strokes. Late reperfusion of tissue that was no longer salvageable could be one explanation, as suggested by previous exploratory studies that showed an association between time to reperfusion and good clinical outcome. We sought to validate this association in a preplanned analysis of data from the IMS III trial.


METHODS
We used data for patients with complete proximal arterial occlusions in the anterior circulation who received endovascular treatment and achieved angiographic reperfusion (score on Thrombolysis in Cerebral Infarction scale of grade 2-3) during the endovascular procedure (within 7 h of symptom onset). We used logistic regression to model good clinical outcome (defined as a modified Rankin Scale score of 0-2 at 3 months) as a function of the time to reperfusion. We prespecified variables to be considered for adjustment, including age, baseline National Institutes of Health Stroke Scale score, sex, and baseline blood glucose concentration.


RESULTS
Of 240 patients who were otherwise eligible for inclusion in our analysis, 182 (76%) achieved angiographic reperfusion. Mean time from symptom onset to reperfusion (ie, procedure end) was 325 min (SD 52). Increased time to reperfusion was associated with a decreased likelihood of good clinical outcome (unadjusted relative risk for every 30-min delay 0·85 [95% CI 0·77-0·94]; adjusted relative risk 0·88 [0·80-0·98]).


CONCLUSIONS
Delays in time to angiographic reperfusion lead to a decreased likelihood of good clinical outcome in patients after moderate to severe stroke. Rapid reperfusion could be crucial for the success of future acute endovascular trials.


BACKGROUND
US National Institutes of Health and National Institute of Neurological Disorders and Stroke.
University of Cincinnati, Cincinnati, OH, USA. Electronic address: pooja.khatri@uc.edu.
Pooja
P
Khatri
Medical University of South Carolina, Charleston, SC, USA.
Sharon D
SD
Yeatts
Paris-Diderot University, Bichat University Hospital, Paris, France.
Mikael
M
Mazighi
University of Cincinnati, Cincinnati, OH, USA.
Joseph P
JP
Broderick
University of California, Los Angeles, Los Angeles, CA, USA.
David S
DS
Liebeskind
University of Calgary, Calgary, AB, Canada.
Andrew M
AM
Demchuk
Paris-Diderot University, Bichat University Hospital, Paris, France.
Pierre
P
Amarenco
University of Cincinnati, Cincinnati, OH, USA.
Janice
J
Carrozzella
University of Cincinnati, Cincinnati, OH, USA.
Judith
J
Spilker
Medical University of South Carolina, Charleston, SC, USA.
Lydia D
LD
Foster
University of Calgary, Calgary, AB, Canada.
Mayank
M
Goyal
University of Calgary, Calgary, AB, Canada.
Michael D
MD
Hill
Medical University of South Carolina, Charleston, SC, USA.
Yuko Y
YY
Palesch
Medical University of South Carolina, Charleston, SC, USA.
Edward C
EC
Jauch
University of Virginia Health System, Charlottesville, VA, USA.
E Clarke
EC
Haley
University of Cincinnati, Cincinnati, OH, USA.
Achala
A
Vagal
University of Cincinnati, Cincinnati, OH, USA.
Thomas A
TA
Tomsick
D000293:Adolescent; D000328:Adult; D000368:Aged; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D002340:Carotid Artery Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D002533:Cerebral Angiography / Q000379:methods; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015424:Reperfusion / Q000009:adverse effects / Q000379:methods*; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D015898:Tomography Scanners, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator