Skip to main content
SpringerLink
Log in

Influence of procedure time on outcome and hemorrhagic transformation in stroke patients undergoing thrombectomy

  • Original Communication
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Background and purpose

Data on procedure time (PT) for mechanical thrombectomy (MT) are scarce. Moreover, the relationship among PT, postprocedural hemorrhagic transformation (HT), and functional outcomes in MT patients remains unclear. We investigated whether postprocedural HT mediated the relationship between PT and functional outcomes in patients with stent-retriever thrombectomy.

Methods

We retrospectively analyzed consecutive patients who underwent MT at two comprehensive stroke centers. PT was defined as the time from puncture to first successful recanalization or to abortion of the procedure if successful recanalization was not achieved. A favorable outcome was defined as a 90-day modified Rankin Scale score of 0–2. HT was classified using the European Cooperative Acute Stroke Study definition.

Results

Among 283 patients (mean age, 67.2 ± 11.9 years; male, 53.7%), 124 (43.8%) patients had a favorable outcome and 27 (9.5%) patients experienced symptomatic intracranial hemorrhage (sICH). Whether in the overall cohort or in the successful recanalization cohort, extended PT was an independent predictor for a poor outcome (per 30 min: OR 1.433, 95% CI 1.062–1.865, p = 0.019; OR 1.522, 95% CI 1.062–2.159, p = 0.020, respectively) and sICH (per 30 min: OR 1.391, 95% CI 1.030–1.865, p = 0.029; OR 1.716, 95% CI 1.161–2.648, p = 0.009, respectively). Moreover, postprocedural HT might partially explain the worse function outcomes in patients with an extended PT (the regression coefficient was changed by 28.2% and 28.1%, respectively).

Conclusions

The PT is an independent predictor for 90-day outcomes in stent-retriever thrombectomy patients. Postprocedural HT was partially responsible for the worse outcome in patients who experienced a longer PT.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Davalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millan M, Davis SM, Roy D, Thornton J, Roman LS, Ribo M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG, Collaborators H (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731

    Article  Google Scholar 

  2. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castano C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro A, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YB, Hill MD, Collaborators H (2016) Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 316:1279–1288

    Article  Google Scholar 

  3. Khatri P, Yeatts SD, Mazighi M, Broderick JP, Liebeskind DS, Demchuk AM, Amarenco P, Carrozzella J, Spilker J, Foster LD, Goyal M, Hill MD, Palesch YY, Jauch EC, Haley EC, Vagal A, Tomsick TA, Trialists II (2014) Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol 13:567–574

    Article  Google Scholar 

  4. Nogueira RG, Smith WS, Sung G, Duckwiler G, Walker G, Roberts R, Saver JL, Liebeskind DS, MERCI, Multi MWC (2011) Effect of time to reperfusion on clinical outcome of anterior circulation strokes treated with thrombectomy: pooled analysis of the MERCI and multi MERCI trials. Stroke 42:3144–3149

    Article  Google Scholar 

  5. Ribo M, Molina CA, Cobo E, Cerda N, Tomasello A, Quesada H, De Miquel MA, Millan M, Castano C, Urra X, Sanroman L, Davalos A, Jovin T, Investigators RT (2016) Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke 47:999–1004

    Article  Google Scholar 

  6. Hassan AE, Chaudhry SA, Miley JT, Khatri R, Hassan SA, Suri MF, Qureshi AI (2013) Microcatheter to recanalization (procedure time) predicts outcomes in endovascular treatment in patients with acute ischemic stroke: when do we stop? AJNR Am J Neuroradiol 34:354–359

    Article  CAS  Google Scholar 

  7. Kass-Hout T, Kass-Hout O, Sun CJ, Kass-Hout TA, Nogueira R, Gupta R (2016) Longer procedural times are independently associated with symptomatic intracranial hemorrhage in patients with large vessel occlusion stroke undergoing thrombectomy. J Neurointerventional Surg 8:1217–1220

    Article  Google Scholar 

  8. Spiotta AM, Vargas J, Turner R, Chaudry MI, Battenhouse H, Turk AS (2014) The golden hour of stroke intervention: effect of thrombectomy procedural time in acute ischemic stroke on outcome. J Neurointerventional Surg 6:511–516

    Article  Google Scholar 

  9. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL (2018) 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110

    Article  Google Scholar 

  10. Alawieh A, Vargas J, Fargen KM, Langley EF, Starke RM, De Leacy R, Chatterjee R, Rai A, Dumont T, Kan P, McCarthy D, Nascimento FA, Singh J, Vilella L, Turk A, Spiotta AM (2019) Impact of procedure time on outcomes of thrombectomy for stroke. J Am Coll Cardiol 73:879–890

    Article  Google Scholar 

  11. Hassan AE, Shariff U, Saver JL, Goyal M, Liebeskind D, Jahan R, Qureshi AI (2019) Impact of procedural time on clinical and angiographic outcomes in patients with acute ischemic stroke receiving endovascular treatment. J Neurointerventional Surg. https://doi.org/10.1136/neurintsurg-2018-014576

    Article  Google Scholar 

  12. Christoforidis GA, Mohammad Y, Kehagias D, Avutu B, Slivka AP (2005) Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke. AJNR Am J Neuroradiol 26:1789–1797

    PubMed  Google Scholar 

  13. Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, Kim LJ, Mayer SA, Sheth KN, Schwamm LH (2017) Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 48:e343–e361

    PubMed  Google Scholar 

  14. Baron RM, Kenny DA (1986) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51:1173–1182

    Article  CAS  Google Scholar 

  15. Kimberly WT, Dutra BG, Boers AMM, Alves H, Berkhemer OA, van den Berg L, Sheth KN, Roos Y, van der Lugt A, Beenen LFM, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ, Lingsma HF, Marquering H, Majoie C, Investigators MC (2018) Association of reperfusion with brain EDEMA in patients with acute ischemic stroke: a secondary analysis of the MR CLEAN trial. JAMA Neurol 75:453–461

    Article  Google Scholar 

  16. Kim J-T, Fonarow GC, Smith EE, Reeves MJ, Navalkele DD, Grotta JC, Grau-Sepulveda MV, Hernandez AF, Peterson ED, Schwamm LH, Saver JL (2017) Treatment With tissue plasminogen activator in the golden hour and the shape of the 4.5-hour time-benefit curve in the National United States get with the guidelines-stroke population. Circulation 135:128–139

    Article  CAS  Google Scholar 

  17. Alawieh A, Pierce AK, Vargas J, Turk AS, Turner RD, Chandry MI, Spiotta AM (2018) The golden 35 min of stroke intervention with ADAPT: effect of thrombectomy procedural time in acute ischemic stroke on outcome. J Neurointerventional Surg 10:213–220

    Article  Google Scholar 

  18. Ribo M, Flores A, Rubiera M, Pagola J, Mendonca N, Rodriguez-Luna D, Pineiro S, Meler P, Alvarez-Sabin J, Molina CA (2013) Difficult catheter access to the occluded vessel during endovascular treatment of acute ischemic stroke is associated with worse clinical outcome. J Neurointerventional Surg 5(Suppl 1):i70–i73

    Article  Google Scholar 

  19. Hao Y, Yang D, Wang H, Zi W, Zhang M, Geng Y, Zhou Z, Wang W, Xu H, Tian X, Lv P, Liu Y, Xiong Y, Liu X, Xu G, for the ACTUAL (Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry) Investigators (2017) Predictors for symptomatic intracranial hemorrhage after endovascular treatment of acute ischemic stroke. Stroke 48:1203–1209

    Article  Google Scholar 

  20. Bourcier R, Saleme S, Labreuche J, Mazighi M, Fahed R, Blanc R, Gory B, Kyheng M, Marnat G, Bracard S, Desal H, Consoli A, Piotin M, Lapergue B (2018) More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke. J Neurointerventional Surg. https://doi.org/10.1136/neurintsurg-2018-014380

    Article  Google Scholar 

  21. Sun CH, Nogueira RG, Glenn BA, Connelly K, Zimmermann S, Anda K, Camp D, Frankel MR, Belagaje SR, Anderson AM, Isakov AP, Gupta R (2013) "Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke. Circulation 127:1139–1148

    Article  CAS  Google Scholar 

  22. Gonzalez NR (2019) Endovascular thrombectomy procedure time and other predictors of futility in acute ischemic stroke interventions. J Am Coll Cardiol 73:891–892

    Article  Google Scholar 

  23. Baek JH, Kim BM, Heo JH, Nam HS, Kim YD, Park H, Bang OY, Yoo J, Kim DJ, Jeon P, Baik SK, Suh SH, Lee KY, Kwak HS, Roh HG, Lee YJ, Kim SH, Ryu CW, Ihn YK, Kim B, Jeon HJ, Kim JW, Byun JS, Suh S, Park JJ, Lee WJ, Roh J, Shin BS (2018) Number of stent retriever passes associated with futile recanalization in acute stroke. Stroke 49:2088–2095

    Article  Google Scholar 

  24. Bai Y, Pu J, Wang H, Yang D, Hao Y, Xu H, Zhang M, Geng Y, Wan Y, Wang W, Zhang H, Zi W, Liu X, Xu G, for the ACTUAL (Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry) Investigators (2018) Impact of retriever passes on efficacy and safety outcomes of acute ischemic stroke treated with mechanical thrombectomy. Cardiovasc Interv Radiol 41:1909–1916

    Article  Google Scholar 

Download references

Funding

This work was supported by the National Natural Science Foundation of China (nos. 81870946, 81771424, 81530038), Natural Science Foundation of Jiangsu Province (no. BE2016748), and National Key Research and Development Program (no. 2017YFC1307901).

Author information

Author notes

  1. Xianjun Huang and Qiankun Cai contributed equally to this work.

Authors and Affiliations

  1. Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, 210002, Jiangsu, China

    Xianjun Huang, Yuanlu Liu, Gelin Xu & Xinfeng Liu

  2. Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui, China

    Xianjun Huang & Zhiming Zhou

  3. Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China

    Qiankun Cai

  4. Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China

    Lulu Xiao & Gelin Xu

  5. Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China

    Mengmeng Gu

  6. Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026, Anhui, China

    Wen Sun & Xinfeng Liu

Authors
  1. Xianjun Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Qiankun Cai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lulu Xiao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mengmeng Gu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yuanlu Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zhiming Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Wen Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Gelin Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xinfeng Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Wen Sun or Xinfeng Liu.

Ethics declarations

Conflicts of interest

There are no conflicts among the authors. All authors read and approved the final submission of the manuscript.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, X., Cai, Q., Xiao, L. et al. Influence of procedure time on outcome and hemorrhagic transformation in stroke patients undergoing thrombectomy. J Neurol 266, 2560–2570 (2019). https://doi.org/10.1007/s00415-019-09451-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-019-09451-5

Keywords

Search

Navigation