Time From Hospital Arrival Until Endovascular Thrombectomy and Patient-Reported Outcomes in Acute Ischemic Stroke

Abstract

Importance: The time-benefit association of endovascular thrombectomy (EVT) in ischemic stroke with patient-reported outcomes is unknown.

Objective: To assess the time-dependent association of EVT with self-reported quality of life in patients with acute ischemic stroke.

Design, setting, and participants: Data were used from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, which tested the effect of nerinetide on functional outcomes in patients with large vessel occlusion undergoing EVT and enrolled patients from March 1, 2017, to August 12, 2019. The ESCAPE-NA1 trial was an international randomized clinical trial that recruited patients from 7 countries. Patients with EuroQol 5-dimension 5-level (EQ-5D-5L) index values at 90 days and survivors with complete domain scores were included in the current study. Data were analyzed from July to September 2023.

Exposure: Hospital arrival to arterial puncture time and other time metrics.

Main outcomes and measures: EQ-5D-5L index scores were calculated at 90 days using country-specific value sets. The association between time from hospital arrival to EVT arterial-access (door-to-puncture) and EQ-5D-5L index score, quality-adjusted life years, and visual analog scale (EQ-VAS) were evaluated using quantile regression, adjusting for age, sex, stroke severity, stroke imaging, wake-up stroke, alteplase, and nerinetide treatment and accounting for clustering by site. Using logistic regression, the association between door-to-puncture time and reporting no or slight symptoms (compared with moderate, severe, or extreme problems) was determined in each domain (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression) or across all domains. Time from stroke onset was also evaluated, and missing data were imputed in sensitivity analyses.

Results: Among 1105 patients in the ESCAPE-NA1 trial, there were 1043 patients with EQ-5D-5L index values at 90 days, among whom 147 had died and were given a score of 0, and 1039 patients (mean [SD] age, 69.0 [13.7] years; 527 male [50.7%]) in the final analysis as 4 did not receive EVT. There were 896 survivors with complete domain scores at 90 days. There was a strong association between door-to-puncture time and EQ-5D-5L index score (increase of 0.03; 95% CI, 0.02-0.04 per 15 minutes of earlier treatment), quality-adjusted life years (increase of 0.29; 95% CI, 0.08-0.49 per 15 minutes of earlier treatment), and EQ-VAS (increase of 1.65; 95% CI, 0.56-2.72 per 15 minutes of earlier treatment). Each 15 minutes of faster door-to-puncture time was associated with higher probability of no or slight problems in each of 5 domains and all domains concurrently (range from 1.86%; 95% CI, 1.14-2.58 for pain or discomfort to 3.55%; 95% CI, 2.06-5.04 for all domains concurrently). Door-to-puncture time less than 60 minutes was associated higher odds of no or slight problems in each domain, ranging from odds ratios of 1.49 (95% CI, 1.13-1.95) for pain or discomfort to 2.59 (95% CI, 1.83-3.68) for mobility, with numbers needed to treat ranging from 7 to 17. Results were similar after multiple imputation of missing data and attenuated when evaluating time from stroke onset.

Conclusions and relevance: Results suggest that faster door-to-puncture EVT time was strongly associated with better health-related quality of life across all domains. These results support the beneficial impact of door-to-treatment speed on patient-reported outcomes and should encourage efforts to improve patient-centered care in acute stroke by optimizing in-hospital processes and workflows.

Figure 1.. Distribution of EuroQol 5-Dimension 5-Level (EQ-5D-5L) Index Scores For Patient Door-to-Puncture Times

Patients with times <60 minutes had substantially higher index scores. The large number of zeroes is due to patients who died by 90 days. Bins are in 0.02 increments.

Figure 2.. Association Between Continuous Door-to-Puncture Times and EuroQol 5-Dimension 5-Level (EQ-5D-5L), Quality-Adjusted Life-Years (QALYs), and EQ–Visual Analog Scale (VAS)

Faster door-to-puncture treatment time was associated with higher predicted EQ-5D-5L index score for all patients (A), and with higher QALYs (B) and EQ-VAS (C). Shaded areas represent 95% CIs. Predicted probabilities obtained from quantile regression models, adjusted for age, sex, wake-up stroke, National Institutes of Health Stroke Scale, Alberta Stroke Program Early Computed Tomography Score, site of occlusion, receipt of nerinitide, and receipt of alteplase.

Figure 3.. Percentage of Patients in Each Domain Level Stratified By Door-to-Puncture Time

A, Mobility. B, Self-care. C, Usual activities. D, Pain or discomfort. E, Anxiety or depression. F, No or slight problems across all 5 domains. Domain levels are as follows: 1 = no problems, 2 = slight problems, 3 = moderate problems, 4 = severe problems, and 5 = extreme problems. When door-to-puncture was less than 60 minutes, there was a higher percentage of patients with no or slight problems in each domain and in all domains concurrently.

Figure 4.. Association Between Continuous Door-to-Puncture Time and Predicted Probability of Reporting No or Slight Problems

A, Mobility. B, Self-care. C, Usual activities. D, Pain or discomfort. E. Anxiety or depression. F, All domains concurrently. Shaded areas represent 95% CIs. Predicted probabilities obtained from logistic regression models, adjusted for age, sex, wake-up stroke, National Institutes of Health Stroke Scale, Alberta Stroke Program Early Computed Tomography Score, site of occlusion, receipt of nerinitide, and receipt of alteplase.