Bourcier R, Goyal M, Liebeskind DS, Muir KW, Desal H, for the HERMES Trialists Collaboration et al. Association of Time From Stroke Onset to Groin Puncture With Quality of Reperfusion After Mechanical Thrombectomy: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol. 2019;76:405–411.
Successful recanalization in anterior circulation ischemic strokes of selected patients is clearly related to a better functional prognosis. Given that time is brain, decreasing the delay in recanalization of the occluded vessel, reduces the final size of the infarction. So we can understand, that faster times in obtaining a TICI 2b-3, improves the functional outcome of the patient. The demonstration of this premise is the objective of the meta-analysis carried out in the present study.
Patients in the intervention group (EVT) of randomized clinical trials of the HERMES group were included in a meta-analysis of anterior circulation ischemic stroke, with M1/M2 or intracranial carotid (ICA) occlusion. Primary endpoint was the rate of successful reperfusion (defined as mTICI 2b-3) at the end of procedure. In addition, the association between differents intervals from onset to groin puncture and the clot burden score (CBS) was evaluated.
Among 728 analyzed patients, median onset to arterial access time was 239 minutes. This meta-analysis demonstrated that successful reperfusion was related to shorter times to arterial access, and also computed tomography to arterial puncture and door to arterial access were associated with mTICI 2b-3. In relation with delays impact, every additional hour between emergency arrival and imaging with groin puncture, were related with a 22% and 26% in the odds of TICI 2b-3 respectively. Imaging-groin puncture time interval, had the strongest association with final reperfusion. Finally, CBS did not vary by time intervals.
It seems clear that the impact of reducing time in the hospital workflow from the stroke patient emergency department arrival to the femoral puncture, benefits reperfusion after endovascular treatment. The conclusions of this study show the importance of improving the stroke team coordination, and the awareness of the relevance of our delays in the transfer of a patient to the angiography room. There are many factors that we can not control yet to improve the functional prognosis of our patients with large vessel occlusion. However, it is possible that ameliorating response times in ischemic stroke, can overcome important obstacles, as collateral or the final composition of the thrombus itself, which seems to be affected by the time. All times are brain, but there are some in which we can act and improve the final result.