title: Association Between Time to Reperfusion and Outcome Is Primarily Driven by the Time From Imaging to Reperfusion.
abstract: OBJECTIVE
  A progressive decline in the odds of favorable outcome as time to reperfusion increases is well known. However, the impact of specific workflow intervals is not clear.
  
  
  METHODS
  We studied the mechanical thrombectomy group (n=103) of the prospective, randomized REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset) trial. We defined 3 workflow metrics: time from symptom onset to reperfusion (OTR), time from symptom onset to computed tomography, and time from computed tomography (CT) to reperfusion. Clinical characteristics, core laboratory-evaluated Alberta Stroke Program Early CT Scores (ASPECTS) and 90-day outcome data were analyzed. The effect of time on favorable outcome (modified Rankin scale, 0-2) was described via adjusted odds ratios (ORs) for every 30-minute delay.
  
  
  RESULTS
  Median admission National Institutes of Health Stroke Scale was 17.0 (14.0-20.0), reperfusion rate was 66%, and rate of favorable outcome was 43.7%. Mean (SD) workflow times were as follows: OTR: 342 (107) minute, onset to CT: 204 (93) minute, and CT to reperfusion: 138 (56) minute. Longer OTR time was associated with a reduced likelihood of good outcome (OR for 30-minute delay, 0.74; 95% confidence interval [CI], 0.59-0.93). The onset to CT time did not show a significant association with clinical outcome (OR, 0.87; 95% CI, 0.67-1.12), whereas the CT to reperfusion interval showed a negative association with favorable outcome (OR, 0.72; 95% CI, 0.54-0.95). A similar subgroup analysis according to admission ASPECTS showed this relationship for OTR time in ASPECTS<8 patients (OR, 0.56; 95% CI, 0.35-0.9) but not in ASPECTS≥8 (OR, 0.99; 95% CI, 0.68-1.44).
  
  
  CONCLUSIONS
  Time to reperfusion is negatively associated with favorable outcome, being CT to reperfusion, as opposed to onset to CT, the main determinant of this association. In addition, OTR was strongly associated to outcome in patients with low ASPECTS scores but not in patients with high ASPECTS scores.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.). marcriboj@hotmail.com.
authors.forename: Marc
authors.initials: M
authors.lastname: Ribo
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Erik
authors.initials: E
authors.lastname: Cobo
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Neus
authors.initials: N
authors.lastname: Cerdà
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Alejandro
authors.initials: A
authors.lastname: Tomasello
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Helena
authors.initials: H
authors.lastname: Quesada
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Maria Angeles
authors.initials: MA
authors.lastname: De Miquel
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Mónica
authors.initials: M
authors.lastname: Millan
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Carlos
authors.initials: C
authors.lastname: Castaño
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Xabier
authors.initials: X
authors.lastname: Urra
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Luis
authors.initials: L
authors.lastname: Sanroman
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Antoni
authors.initials: A
authors.lastname: Dàvalos
authors.affiliation: From the Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d'Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Stroke Unit, Section of Interventional Neuroradiology, Department of Neurosciences. Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., C.C.); Departments of Neurology (X.U., A.D.) and Radiology (L.S.), Hospital Clínic, Barcelona, Spain; and Department of Neurology, The Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.).
authors.forename: Tudor
authors.initials: T
authors.lastname: Jovin
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000601:surgery*; D017131:Thrombectomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D057188:Workflow
keywords: odds ratio; probability; reperfusion; stroke; thrombectomy