Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the Interventional Management of Stroke III trial

Abstract

Background: Meaningful delays occurred in the Interventional Management of Stroke (IMS) III trial. Analysis of the work flow will identify factors contributing to the in-hospital delays.

Methods and results: In the endovascular arm of the IMS III trial, the following time intervals were calculated: stroke onset to emergency department arrival; emergency department to computed tomography (CT); CT to intravenous tissue plasminogen activator start; intravenous tissue plasminogen activator start to randomization; randomization to groin puncture; groin puncture to thrombus identification; thrombus identification to start of endovascular therapy; and start of endovascular therapy to reperfusion. The effects of enrollment time, CT angiography use, interhospital transfers, and intubation on work flow were evaluated. Delays occurred notably in the time intervals from intravenous tissue plasminogen activator initiation to groin puncture (median 84 minutes) and start of endovascular therapy to reperfusion (median 85 minutes). The CT to groin puncture time was significantly shorter during working hours than after. Times from emergency department to reperfusion and groin puncture to reperfusion decreased over the trial period. Patients with CT angiography had shorter emergency department to reperfusion and onset to reperfusion times. Transfer of patients resulted in a longer onset to reperfusion time compared with those treated in the same center. Age, sex, National Institutes of Health Stroke Scale score, and intubation did not affect delays.

Conclusions: Important delays were identified before reperfusion in the IMS III trial. Delays decreased as the trial progressed. Use of CT angiography and endovascular treatment in the same center were associated with time savings. These data may help in optimizing work flow in current and future endovascular trials.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.

Keywords: cerebrovascular disease; infarction; stroke.

Conflict of interest statement

Conflict of Interest Disclosures: M. Goyal received a modest research Grant from Covidien. He is a paid consultant for Covidien. He received lecture fees from Covidien and owns Stock in Calgary Scientific and NoNO. M.A. Almekhlafi has nothing to disclose. L. Fan has nothing to disclose. B. Menon received research Support from Heart and Stroke Foundation of Canada Research Scholarship. A. Demchuk received Grant support and lecture fees Covidien. S.D. Yeatts has nothing to disclose. M. Hill received research grant from Hoffman-La Roche Canada, and Heart and Stroke Foundation of Alberta. . He is a paid consultant for Vernalis Group. He received lecture fees from Hoffman-La Roche Canada and owns Stock in Calgary Scientific,. T. Tomsick received Research Grant; from Covidien. P. Khatri serves as an expert Witness in Medico-Legal Consulting. She is a paid consultant for Penumbra, Genentech, and Janssen Pharmaceuticals. She received travel support from Genentech. O. Zaidat has nothing to disclose. E. Jauch has nothing to disclose. Muneer Eesa has nothing to disclose. T.G. Jovin is a paid consultant for Silk Road Medical and owns Stock in Silk Road Medical. J.P. Broderick received Lecture fees from Oakstone Publishing and consulting fees from PhotoThera.

© 2014 American Heart Association, Inc.

Figures

Figure 1

Various time intervals in patients treated within the same institution (mother-ship) vs. those who were transferred from another before (ship and drip) or after (drip and ship) IV tPA therapy. (CTA: CT angiogram, ED: emergency department, IA: start of endovascular therapy, ID: thrombus identification, IV tPA: intravenous tPA, Puncture: groin puncture; Rand: randomization).

Figure 2

Time intervals in patients investigated by CT and CTA vs. CT alone. (CTA: CT angiogram, ED: emergency department, IA: start of endovascular therapy, ID: thrombus identification, IV tPA: intravenous tPA, Puncture: groin puncture; Rand: randomization).

Figure 3

Time intervals in patients investigated by CT and CTA vs. CT alone in the mother-ship paradigm only. (CTA: CT angiogram, ED: emergency department, IA: start of endovascular therapy, ID: thrombus identification, IV tPA: intravenous tPA, Puncture: groin puncture; Rand: randomization).

Figure 4

Time intervals in patients who underwent endovascular procedures during working hours (Mon-Fri; 0800-1700) compared to patients treated outside these hours. (CTA: CT angiogram, ED: emergency department, IA: start of endovascular therapy, ID: thrombus identification, IV tPA: intravenous tPA, Puncture: groin puncture; Rand: randomization).

Figure 5

The change in the time from ED arrival until reperfusion by enrollment quartile. (Mins: minutes)