Impact of time-to-reperfusion on outcome in patients with poor collaterals.
OBJECTIVE
The relationship between reperfusion and clinical outcome is time-dependent, and the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. We aimed to identify the impact of time-to-reperfusion on outcome relative to baseline angiographic collateral grade in patients successfully treated with endovascular revascularization for acute large-vessel anterior circulation stroke.


METHODS
Two hundred seven patients were selected for analysis from our prospectively maintained registry. Inclusion criteria were M1 MCA ± ICA occlusions, onset-to-puncture time within 8 hours, and successful endovascular reperfusion. Baseline angiographic collateral grades were independently evaluated and dichotomized into poor (0-1) versus good (2-4). Multivariable analyses were performed to identify the effect of collateral-flow adequacy on favorable outcome on the basis of onset-to-reperfusion time and puncture-to-reperfusion time.


RESULTS
In the poor collateral group, the odds of favorable outcome significantly dropped for patients with onset-to-reperfusion time of >300 minutes or puncture-to-reperfusion time of >60 minutes (onset-to-puncture time: ≤300, 59% versus >300, 32%; OR, 0.24; P = .011; puncture-to-reperfusion time: ≤60, 73% versus >60, 32%; OR, 0.21, P = .011), whereas the probability of favorable outcome in the good collateral group was not significantly influenced by onset-to-reperfusion time or puncture-to-reperfusion time. In the subgroup lesion-volume growth analysis by using DWI, the effect of puncture-to-reperfusion time of >60 minutes was significantly greater compared with the effect of puncture-to-reperfusion time of <60 minutes in the poor collateral group (β = 41.6 cm(3), P = .001).


CONCLUSIONS
Time-to-reperfusion including onset-to-reperfusion time and puncture-to-reperfusion time in patients with poor collaterals is an important limiting factor for favorable outcome in a time-dependent fashion. Future trials may benefit from a noninvasive imaging technique to detect poor collaterals along with a strategy for rapid reperfusion.
From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea yangha.hwang@gmail.com.
Y-H
http://orcid.org/0000-0002-6665-7481
YH
Hwang
Neurosurgery (D.-H.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea.
D-H
DH
Kang
From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea.
Y-W
YW
Kim
Radiology (D.-H.K., Y.-W.K., Y.-S.K.) Cerebrovascular Center (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, Korea School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea.
Y-S
YS
Kim
From the Departments of Neurology (Y.-H.H., Y.-W.K., S.-P.P.) School of Medicine (Y.-H.H., D.-H.K., Y.-W.K., Y.-S.K., S.-P.P.), Kyungpook National University, Daegu, Korea.
S-P
SP
Park
UCLA Stroke Center (D.S.L.), University of California, Los Angeles, Los Angeles, California.
D S
DS
Liebeskind
D000368:Aged; D020520:Brain Infarction / Q000503:physiopathology / Q000628:therapy*; D003097:Collateral Circulation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015424:Reperfusion; D020521:Stroke / Q000628:therapy*; D061665:Time-to-Treatment