Analysis of Workflow and Time to Treatment and the Effects on Outcome in Endovascular Treatment of Acute Ischemic Stroke: Results from the SWIFT PRIME Randomized Controlled Trial.
Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps. Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances. Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P < .001). Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. (©) RSNA, 2016 Online supplemental material is available for this article.
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Mayank
M
Goyal
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Ashutosh P
AP
Jadhav
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Alain
A
Bonafe
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Hans
H
Diener
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Vitor
V
Mendes Pereira
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Elad
E
Levy
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Blaise
B
Baxter
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Tudor
T
Jovin
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Reza
R
Jahan
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Bijoy K
BK
Menon
From the Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., B.K.M.); Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.P.J., T.J.); Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.D.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada (V.M.P.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (E.L.); Department of Radiology, Erlanger Hospital at the University of Tennessee, Chattanooga, Tenn (B.B.); and Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, Calif.
Jeffrey L
JL
Saver
D000208:Acute Disease; D061605:Administration, Intravenous; D003131:Combined Modality Therapy; D006801:Humans; D007258:Informed Consent; D016015:Logistic Models; D020521:Stroke / Q000628:therapy*; D017131:Thrombectomy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome; D057188:Workflow
D010959:Tissue Plasminogen Activator