Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients

Makenna Ash; Laurie Dimisko; Reda M Chalhoub; Brian M Howard; C Michael Cawley; Charles Matouk; Aqueel Pabaney; Alejandro M Spiotta; Pascal Jabbour; Ilko Maier; Stacey Q Wolfe; Ansaar T Rai; Joon-Tae Kim; Marios-Nikos Psychogios; Justin R Mascitelli; Robert M Starke; Amir Shaban; Shinichi Yoshimura; Reade De Leacy; Peter Kan; Isabel Fragata; Adam J Polifka; Adam S Arthur; Min S Park; Roberto Javier Crosa; Richard Williamson; Travis M Dumont; Michael R Levitt; Sami Al Kasab; Stavropoula I Tjoumakaris; Jan Liman; Hassan Saad; Edgar A Samaniego; Kyle M Fargen; Jonathan A Grossberg; Ali Alawieh; STAR collaborators

doi:10.1136/jnis-2023-020792

Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients

J Neurointerv Surg. 2023 Oct 24:jnis-2023-020792. doi: 10.1136/jnis-2023-020792. Online ahead of print.

Authors

Makenna Ash¹, Laurie Dimisko², Reda M Chalhoub³, Brian M Howard^{1

4}, C Michael Cawley¹, Charles Matouk⁵, Aqueel Pabaney⁶, Alejandro M Spiotta³, Pascal Jabbour⁷, Ilko Maier⁸, Stacey Q Wolfe⁹, Ansaar T Rai¹⁰, Joon-Tae Kim¹¹, Marios-Nikos Psychogios¹², Justin R Mascitelli¹³, Robert M Starke^{14

15}, Amir Shaban¹⁶, Shinichi Yoshimura¹⁷, Reade De Leacy¹⁸, Peter Kan¹⁹, Isabel Fragata²⁰, Adam J Polifka²¹, Adam S Arthur^{22

23}, Min S Park²⁴, Roberto Javier Crosa²⁵, Richard Williamson²⁶, Travis M Dumont²⁷, Michael R Levitt²⁸, Sami Al Kasab²⁹, Stavropoula I Tjoumakaris⁷, Jan Liman⁸, Hassan Saad¹, Edgar A Samaniego³⁰, Kyle M Fargen³¹, Jonathan A Grossberg³², Ali Alawieh³³; STAR collaborators

Affiliations

¹ Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
² Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA.
³ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴ Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
⁵ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
⁶ Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA.
⁷ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
⁸ Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany.
⁹ Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
¹⁰ Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA.
¹¹ Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea.
¹² Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹³ Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
¹⁴ Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁵ University of Miami School of Medicine, Miami, Florida, USA.
¹⁶ Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.
¹⁷ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
¹⁸ Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁹ Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
²⁰ Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²¹ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²² Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
²³ Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
²⁴ Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
²⁵ Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
²⁶ Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA.
²⁷ Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA.
²⁸ Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²⁹ Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
³⁰ Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
³¹ Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA.
³² Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA ali.mostafa.alawieh@emory.edu jonathan.a.grossberg@emory.edu.
³³ Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA ali.mostafa.alawieh@emory.edu jonathan.a.grossberg@emory.edu.

PMID: 37875342
DOI: 10.1136/jnis-2023-020792

Abstract

Objective: To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.

Methods: This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation.

Results: Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time.

Conclusions: In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.

Keywords: stroke; thrombectomy.