Background and Purpose: Endovascular therapy (EVT) for acute ischemic stroke (AIS) is now proven by pivotal randomized controlled trials (RCTs) to produce clinically large benefits. In early 2015, following publication of these RCTs, we implemented a new institutional acute stroke care protocol to improve outcomes of patients with AIS, especially by reducing onset-to-reperfusion (OTR) time. We sought to analyze the temporal trends in EVT for AIS at our hospital and evaluate the effect of this intervention.
Methods: We analyzed the temporal trends in EVT for AIS and compared patients who underwent EVT for AIS in the pre intervention (April 2010 - March 2015) and post intervention (April 2015 - March 2017) period. Using univariate methods and multivariable logistic regression, we assessed the associated factors with favorable outcomes.
Results: Among 2657 patients with AIS, 322 (12.1%) underwent EVT. The mean age was 74.4 and the median baseline NIHSS was 19. The percentage of patients with EVT significantly increased from 9.7% pre intervention to 18.0% post intervention. Patients over 90 years old, with M2 occlusion, and received IV-tPA were significantly increased in post intervention period (P<0.01). The median (interquartile range) door-to-puncture (DTP) times was reduced from 120 (93-144) minutes to 52 (39-73) minutes (p<0.001), and OTR times was reduced from 368 (263-554) minutes to 256 (163-440) minutes (P=0.006). The percentage of patients with favorable outcomes (modified Rankin scales 0-2 at 90days) improved from 28.8% to 39.9%. Multivariable model showed an association of favorable outcomes with younger age (OR 0.93, 95%CI 0.90-0.96, P<0.001), lower baseline NIHSS (OR 0.89, 95% CI 0.85-0.93, P<0.001), administration of tPA (OR 2.17, 95%CI 1.05-4.49, P=0.038), and shorter OTR times (per10min, OR 0.99, 95%CI 0.97-1.00, P=0.047).
Conclusions: EVT for AIS accelerated markedly in the two years following RCTs publication and our new institutional acute stroke care protocol reduced DTP and OTR times. Reducing OTR times was associated with improving patient outcomes.