Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study

Bijoy K Menon; Mohammed A Almekhlafi; Vitor Mendes Pereira; Jan Gralla; Alain Bonafe; Antoni Davalos; Rene Chapot; Mayank Goyal; STAR Study Investigators

doi:10.1161/STROKEAHA.114.005050

Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study

Stroke. 2014 Jul;45(7):2024-9. doi: 10.1161/STROKEAHA.114.005050. Epub 2014 May 15.

Authors

Bijoy K Menon¹, Mohammed A Almekhlafi¹, Vitor Mendes Pereira¹, Jan Gralla¹, Alain Bonafe¹, Antoni Davalos¹, Rene Chapot¹, Mayank Goyal²; STAR Study Investigators

Affiliations

¹ 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.).
² 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.

PMID: 24876244
DOI: 10.1161/STROKEAHA.114.005050

Abstract

Background and purpose: 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.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT01327989.

Keywords: cerebrovascular accident; emergency; stroke.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Aged, 80 and over
Angiography, Digital Subtraction / standards
Brain Ischemia / diagnostic imaging
Brain Ischemia / drug therapy
Brain Ischemia / surgery
Brain Ischemia / therapy*
Cerebrovascular Circulation*
Clinical Trials as Topic / standards
Female
Humans
Male
Middle Aged
Outcome and Process Assessment, Health Care / standards*
Prospective Studies
Reperfusion
Stents / statistics & numerical data
Stroke / diagnostic imaging
Stroke / drug therapy
Stroke / surgery
Stroke / therapy*
Thrombectomy / instrumentation
Thrombectomy / standards*
Thrombolytic Therapy / standards*
Time Factors
Workflow*

Associated data

ClinicalTrials.gov/NCT01327989