title: Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study.
abstract: OBJECTIVE
  We report on workflow and process-based performance measures and their effect on clinical outcome in Solitaire FR Thrombectomy for Acute Revascularization (STAR), a multicenter, prospective, single-arm study of Solitaire FR thrombectomy in large vessel anterior circulation stroke patients.
  
  
  METHODS
  Two hundred two patients were enrolled across 14 centers in Europe, Canada, and Australia. The following time intervals were measured: stroke onset to hospital arrival, hospital arrival to baseline imaging, baseline imaging to groin puncture, groin puncture to first stent deployment, and first stent deployment to reperfusion. Effects of time of day, general anesthesia use, and multimodal imaging on workflow were evaluated. Patient characteristics and workflow processes associated with prolonged interval times and good clinical outcome (90-day modified Rankin score, 0-2) were analyzed.
  
  
  RESULTS
  Median times were onset of stroke to hospital arrival, 123 minutes (interquartile range, 163 minutes); hospital arrival to thrombolysis in cerebral infarction (TICI) 2b/3 or final digital subtraction angiography, 133 minutes (interquartile range, 99 minutes); and baseline imaging to groin puncture, 86 minutes (interquartile range, 24 minutes). Time from baseline imaging to puncture was prolonged in patients receiving intravenous tissue-type plasminogen activator (32-minute mean delay) and when magnetic resonance-based imaging at baseline was used (18-minute mean delay). Extracranial carotid disease delayed puncture to first stent deployment time on average by 25 minutes. For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%.
  
  
  CONCLUSIONS
  Interval times in the STAR study reflect current intra-arterial therapy for patients with acute ischemic stroke. Improving workflow metrics can further improve clinical outcome.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT01327989.
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Bijoy K
authors.initials: BK
authors.lastname: Menon
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Almekhlafi
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Vitor Mendes
authors.initials: VM
authors.lastname: Pereira
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Jan
authors.initials: J
authors.lastname: Gralla
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Alain
authors.initials: A
authors.lastname: Bonafe
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Antoni
authors.initials: A
authors.lastname: Davalos
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.).
authors.forename: Rene
authors.initials: R
authors.lastname: Chapot
authors.affiliation: From the Department of Clinical Neurosciences, Hotchkiss Brain Institute (B.K.M., M.A.A., M.G.), Department of Radiology (B.K.M., M.A.A., M.G.), and Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.P.); Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland (J.G.); Department of Neuroradiology, CHU de Montpellier-Guy de Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); and Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.). mgoyal@ucalgary.ca.
authors.forename: Mayank
authors.initials: M
authors.lastname: Goyal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction / Q000592:standards; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D002560:Cerebrovascular Circulation; D002986:Clinical Trials as Topic / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D011446:Prospective Studies; D015424:Reperfusion; D015607:Stents / Q000706:statistics & numerical data; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D017131:Thrombectomy / Q000295:instrumentation / Q000592:standards*; D015912:Thrombolytic Therapy / Q000592:standards*; D013997:Time Factors; D057188:Workflow
keywords: cerebrovascular accident; emergency; stroke