The Relationship between Treatment Speed of Endovascular Thrombectomy (EVT) for Acute Ischemic Stroke and Patient’s “Time at Home”

Stroke is an acute disease with high disability and mortality rates. However, in recent years, the treatment efficacy of acute ischemic stroke has improved significantly with the development of endovascular thrombectomy (EVT) techniques. Multiple key clinical trials have demonstrated that EVT has a significant effect on patients with large vessel occlusion stroke, improving functional independence and quality of life (Modified Rankin Scale, mRS) at 90 days. However, in these studies, the effectiveness of EVT was closely related to the treatment speed; the faster the treatment, the better the functional recovery. Nevertheless, the relationship between EVT treatment speed and the patient-prioritized “time at home” remains unclear. This paper aims to investigate the relationship between EVT treatment speed and time at home, providing a more comprehensive assessment of patient outcomes.

Research Background

In stroke research, some traditional patient-reported outcomes (PROs), such as mRS, face issues like difficulty in follow-up, high mortality rates, and the influence of stroke severity on participation. “Time at home” is a novel patient-centered outcome measure, defined as the number of days a patient spends at home within a specified time after a stroke. This measure is obtained through administrative data linkage and has been validated as a proxy for functional outcomes.

Previous research has shown that patients receiving EVT treatment increased their time at home by 8.5 days within 90 days compared to those not receiving EVT treatment. However, the decisive role of treatment speed on the effectiveness of EVT is evident. While studies have shown that treatment speed is associated with an increased proportion of patients discharged home, no research has explored the broader impact of treatment speed on 90-day time at home.

Research Source

This paper was authored by Dr. Raed A. Joundi and colleagues from institutions such as Hamilton Health Sciences, McMaster University, Population Health Research Institute, and the University of Calgary. The paper was published in the journal Neurology in 2024, and the research data was sourced from the Quality Improvement and Clinical Research Registry (QUICR).

Research Methods

Study Setting, Data Source, and Participants

The study data came from the QUICR registry, which included all patients receiving intravenous thrombolysis and/or EVT for acute ischemic stroke starting from April 1, 2015. The study setting was the province of Alberta, Canada, with a total population of approximately 4 million and two comprehensive stroke centers and 15 primary stroke centers. The QUICR registry data was deterministically linked with administrative databases from Alberta Health, which provides universal health insurance coverage to over 99% of residents. The study extracted all EVT cases from April 2015 to December 2022, excluding non-Alberta residents.

Exposures and Covariates

Collected covariates included age, sex, pre-stroke severity (NIH Stroke Scale, NIHSS score), stroke onset time or last known well time, hospital arrival time, and whether intravenous thrombolysis was received. The primary exposure was the time from stroke onset to arterial puncture (Onset-to-Puncture Time), and the secondary exposure was the time from hospital arrival to arterial puncture (Door-to-Puncture Time). These time variables were categorized for analysis.

Primary Outcome: 90-Day Time at Home

The primary outcome measure was the number of days spent at home within 90 days after stroke onset. Time at home included days spent outside healthcare facilities, with deceased patients having a time at home of zero. Data was sourced from Alberta administrative databases, and socioeconomic status (SES) information was obtained through postal codes.

Statistical Analysis

Baseline characteristics across treatment time categories were analyzed, and restricted cubic splines were used to evaluate the relationship between continuously changing time variables and higher time at home. To assess the linear relationship between treatment speed and 90-day time at home, zero-inflated negative binomial regression models were employed.

Research Results

The study included 1,885 patients who received EVT treatment and found that patients treated faster were more likely to come from higher socioeconomic status communities and urban areas. Faster treatment speeds were associated with longer time at home, especially for treatment within 6 hours of stroke onset and 2 hours of hospital arrival.

Adjusted results showed that for every 13 minutes earlier treatment, patients gained 1 additional day at home.

Data plots showed a trend towards higher time at home categories for patients treated more rapidly. Additionally, continued earlier treatment was significantly associated with higher time at home within the first few hours.

Discussion

This study demonstrates a clear relationship between EVT treatment speed for stroke and patient time at home. Early treatment within the first 4 hours is most crucial, with every 12.8 minutes earlier treatment resulting in an additional day at home. These findings reinforce the importance of optimizing stroke treatment speed in pre-hospital and in-hospital pathways and highlight the utility of time at home as a valuable measure of stroke treatment efficacy assessment.

By validating the relationship with traditional clinical outcome measures (e.g., mRS and NIHSS scores), the study further underscores the applicability of time at home for analyzing treatment effects in routine datasets.

These findings have important practical implications for future stroke treatment and system optimization.

Scientific Value and Practical Applications

This research provides valuable evidence on the relationship between EVT treatment speed and patient time at home, emphasizing the importance of early treatment for acute ischemic stroke patients. The results will aid in optimizing clinical pathways for stroke treatment, improving patient quality of life, and reducing healthcare system costs. Furthermore, the novel outcome measure of “time at home” has immense potential for application in medical research and clinical practice.

Research Highlights

1. Elucidates the relationship between stroke treatment speed and the patient-prioritized “time at home.”
2. Emphasizes the critical role of treatment speed in regaining function and improving quality of life for acute ischemic stroke patients.
3. Provides important evidence for further optimizing stroke treatment processes in the medical field.

These research findings not only offer a scientific understanding of the critical impact of EVT treatment speed but also provide solid theoretical and data support for quality improvement in clinical practice.