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Timing Is Brain: The Impact of Endovascular Therapy Start Time on Neurological Outcome
27 Pages Posted: 25 Jun 2019
More...Abstract
Background: The increasing number of patients eligible for endovascular therapy (EVT) could be a potential source of fatigue for the stroke management team leading to poor outcome. We sought to investigate the association between EVT start time in acute ischemic stroke (AIS) and long-term neurological outcome.
Methods: In this retrospective cohort study, 1,558 cases treated by EVT from January 2012 to December 2018 were analysed using stroke registries from two tertiary stroke centres. The primary endpoint was the score on the the modified Rankin Scale (mRS) at 90 days. A proportional odds model was used to calculate the common odds ratio (OR) as a measure of the likelihood that the intervention at a given EVT start time would lead to lower scores on the mRS than at other EVT start times. Secondary endpoints were EVT start-to-recanalisation time, modified treatment in cerebral ischemia score, number of EVT passes and rate of symptomatic intracranial haemorrhage.
Findings: Symptom onset-to-EVT start time was significantly higher and use of IV tPA significantly lower between 10:20-11:34 (P<0·004 and P=0·012, respectively). The primary endpoint favored EVT start times in the morning at 08:00-10:20 and 10:20-11:34 (OR, 0·53; 95% confidence interval (CI), 0·37-0·75; P<0·001; OR, 0·62; 95% CI, 0·44-0·87; P=0·006, respectively), while it disfavored EVT start times at the end of the working day at 15:55-17:15 (OR, 1·47; 95% CI, 1·03-2·09; P=0·033) and 18:55-20:55 (OR, 1·54; 95% CI, 1·07-2·22; P=0·020). No statistical difference was observed in the secondary endpoints between any time periods.
Interpretation: EVT for AIS in the morning leads to better long-term neurological outcome, despite having a statistically longer symptom onset-to-EVT start time, while EVT at the end of the work day leads to poorer long-term neurological outcome. Neither difference in baseline factors, standard workflow and technical efficacy metrics could be identified as potential mediators of this effect.
Funding Statement: The authors stated: No funding was provided for this study.
Declaration of Interests: The authors certify that they have no affiliations with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethics Approval Statement: The study was approved by the local institutional review board of each hospital under the auspices of the Swiss ethics committees for research involving humans (Swissethics). No informed consent was required according to the legislation.
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