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

Lancet Neurol. 2014 Jun;13(6):567-74. doi: 10.1016/S1474-4422(14)70066-3. Epub 2014 Apr 27.


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.

Findings: 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]).

Interpretation: 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.

Funding: US National Institutes of Health and National Institute of Neurological Disorders and Stroke.

Publication types

  • Clinical Trial, Phase III
  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Brain Ischemia* / diagnostic imaging
  • Brain Ischemia* / drug therapy
  • Brain Ischemia* / surgery
  • Carotid Artery Diseases / diagnostic imaging
  • Carotid Artery Diseases / drug therapy
  • Carotid Artery Diseases / surgery
  • Cerebral Angiography / methods
  • Endovascular Procedures / adverse effects
  • Endovascular Procedures / methods*
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Humans
  • Infarction, Middle Cerebral Artery / diagnostic imaging
  • Infarction, Middle Cerebral Artery / drug therapy
  • Infarction, Middle Cerebral Artery / surgery
  • Male
  • Middle Aged
  • Reperfusion / adverse effects
  • Reperfusion / methods*
  • Stroke* / diagnostic imaging
  • Stroke* / drug therapy
  • Stroke* / surgery
  • Time Factors
  • Tissue Plasminogen Activator / administration & dosage
  • Tomography Scanners, X-Ray Computed
  • Treatment Outcome
  • Young Adult


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator