Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Hassan Saad¹, Andrew B Koo², Jonathan A Grossberg¹, Ma Tianwen³, Brian M Howard¹, Mohammad-Mahdi Sowlat⁴, Bachar El Baba¹, Ariana Chacon¹, Pascal Jabbour⁵, Ansaar Rai⁶, Justin Dye⁷, Ali Alaraj⁸, C Michael Cawley¹, Frank C Tong⁹, Feras Akbik¹⁰, Aqueel Pabaney¹¹, Mohamad Ezzeldin¹², David Fiorella¹³, Shinichi Yoshimura¹⁴, Joon-Tae Kim¹⁵, Nitin Goyal¹⁶, Adam S Arthur^{16

17}, Isabel Fragata¹⁸, Fazeel M Siddiqui¹⁹, Justin Mascitelli²⁰, Charles Matouk²¹, Ilko Maier²², Min S Park²³, Michael Levitt²⁴, Ramesh Grandhi²⁵, Marios-Nikos Psychogios²⁶, Stacey Q Wolfe²⁷, Robert M Starke^{28

29}, Amir Shaban³⁰, Edgar A Samaniego³¹, Omar Tanweer³², Daniele G Romano³³, Pedro Navia³⁴, Hugo H Cuellar³⁵, Adam J Polifka³⁶, Josh Osbun³⁷, Mark E Moss³⁸, Kaustubh Limaye³⁹, Maxim Mokin⁴⁰, Waleed Brinjikji⁴¹, Ergun Daglioglu⁴², Richard Williamson⁴³, David Altschul⁴⁴, Christopher S Ogilvy⁴⁵, Roberto Javier Crosa⁴⁶, Benjamin Gory⁴⁷, Alexandra R Paul⁴⁸, Peter Kan⁴⁹, Walter Casagrande⁵⁰, Shakeel A Chowdhry⁵¹, Michael F Stiefel⁵², Alejandro M Spiotta⁴, Ali M Alawieh^{53

54}; Stroke Thrombectomy and Aneurysm Registry (STAR)

Affiliations

¹ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
² Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA.
³ Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.
⁴ Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁵ Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁶ Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
⁷ Neurosurgery, Loma Linda University Health, Loma Linda, California, USA.
⁸ Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA.
⁹ Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁰ Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
¹¹ Emory University, Atlanta, Georgia, USA.
¹² Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA.
¹³ Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.
¹⁴ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁵ Department of Neurology, Chonnam National University Hospital, Dong-gu, Korea (the Republic of).
¹⁶ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹⁷ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁸ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
¹⁹ Neuroscience, Metro Health Hospital, Wyoming, Michigan, USA.
²⁰ Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²¹ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²² Neurology, Universitätsmedizin Göttingen, Göttingen, Germany.
²³ Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁴ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²⁵ Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁶ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
²⁷ Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
²⁸ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
²⁹ University of Miami School of Medicine, Miami, Florida, USA.
³⁰ Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.
³¹ Neurology, University of Iowa Health Care, Iowa City, Iowa, USA.
³² NYU Langone Health, New York, New York, USA.
³³ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
³⁴ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Department of Radiology and Interventional Radiology, LSU Health Shreveport, Shreveport, Louisiana, USA.
³⁶ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
³⁷ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
³⁸ Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA.
³⁹ Department of Neurology, Indiana University, Bloomington, Indiana, USA.
⁴⁰ Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
⁴¹ Mayo Clinic Minnesota, Rochester, Minnesota, USA.
⁴² Neurosurgery, Ministry of Health Ankara Bilkent City Hospital, Çankaya, Turkey.
⁴³ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
⁴⁴ Department of Neurosurgery, Montefiore Medical Center, New York, New York, USA.
⁴⁵ Neurosurgery, BIDMC, Boston, Massachusetts, USA.
⁴⁶ Endovascular Neurosurgery, Medica Uruguaya, Montevideo, Montevideo, Uruguay.
⁴⁷ Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France.
⁴⁸ Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
⁴⁹ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
⁵⁰ Neurosurgery, Hospital Juan A. Fernandez, Buenos Aires, Argentina.
⁵¹ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
⁵² Vascular Neurosurgery, Piedmont Healthcare Inc, Atlanta, Georgia, USA.
⁵³ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA ali.mostafa.alawieh@emory.edu.
⁵⁴ Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA.

PMID: 40973492
DOI: 10.1136/jnis-2025-023906

Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Hassan Saad et al. J Neurointerv Surg. 2025.

. 2025 Sep 19:jnis-2025-023906.

doi: 10.1136/jnis-2025-023906. Online ahead of print.

Authors

Affiliations

¹ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
² Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA.
³ Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.
⁴ Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
⁵ Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁶ Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
⁷ Neurosurgery, Loma Linda University Health, Loma Linda, California, USA.
⁸ Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA.
⁹ Radiology, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁰ Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
¹¹ Emory University, Atlanta, Georgia, USA.
¹² Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA.
¹³ Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.
¹⁴ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁵ Department of Neurology, Chonnam National University Hospital, Dong-gu, Korea (the Republic of).
¹⁶ Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹⁷ Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
¹⁸ Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
¹⁹ Neuroscience, Metro Health Hospital, Wyoming, Michigan, USA.
²⁰ Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²¹ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²² Neurology, Universitätsmedizin Göttingen, Göttingen, Germany.
²³ Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁴ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²⁵ Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁶ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
²⁷ Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
²⁸ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
²⁹ University of Miami School of Medicine, Miami, Florida, USA.
³⁰ Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA.
³¹ Neurology, University of Iowa Health Care, Iowa City, Iowa, USA.
³² NYU Langone Health, New York, New York, USA.
³³ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
³⁴ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁵ Department of Radiology and Interventional Radiology, LSU Health Shreveport, Shreveport, Louisiana, USA.
³⁶ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
³⁷ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
³⁸ Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA.
³⁹ Department of Neurology, Indiana University, Bloomington, Indiana, USA.
⁴⁰ Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
⁴¹ Mayo Clinic Minnesota, Rochester, Minnesota, USA.
⁴² Neurosurgery, Ministry of Health Ankara Bilkent City Hospital, Çankaya, Turkey.
⁴³ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
⁴⁴ Department of Neurosurgery, Montefiore Medical Center, New York, New York, USA.
⁴⁵ Neurosurgery, BIDMC, Boston, Massachusetts, USA.
⁴⁶ Endovascular Neurosurgery, Medica Uruguaya, Montevideo, Montevideo, Uruguay.
⁴⁷ Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France.
⁴⁸ Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
⁴⁹ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
⁵⁰ Neurosurgery, Hospital Juan A. Fernandez, Buenos Aires, Argentina.
⁵¹ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
⁵² Vascular Neurosurgery, Piedmont Healthcare Inc, Atlanta, Georgia, USA.
⁵³ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA ali.mostafa.alawieh@emory.edu.
⁵⁴ Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA.

PMID: 40973492
DOI: 10.1136/jnis-2025-023906

Abstract

Background: Endovascular thrombectomy (EVT) has transformed acute ischemic stroke (AIS) care, with onset-to-puncture (OTP) time widely recognized as a critical determinant of outcome. However, emerging evidence suggests that in-hospital procedure time (PT)-from arterial puncture to final recanalization-may have an equally or more significant impact. This study examines the relative contribution of PT versus OTP to functional outcomes in patients with AIS undergoing EVT.

Methods: A retrospective analysis was conducted of 6644 patients with AIS treated at 44 international stroke centers from the Stroke Thrombectomy and Aneurysm Registry (STAR; 2016-2023). Multivariable regression, time-equivalence analysis, and marginal effects modeling were used to assess associations between PT, OTP, and 90-day modified Rankin Scale (mRS) outcomes. Centers were stratified by procedural efficiency and compared using propensity score matching (PSM). Mediation analysis evaluated whether PT accounted for inter-center differences.

Results: PT and OTP were independently associated with functional outcomes; however, PT had a significantly stronger effect (adjusted OR for mRS 0-2: PT=0.56 vs OTP=0.96 per hour). Each 5 min increase in PT was equivalent to 78-100 min of additional OTP in outcome impact. Centers with faster average PT had higher rates of functional independence (number needed to treat (NNT)=10), fewer complications, and lower symptomatic intracranial hemorrhage rates. PT significantly mediated the relationship between center tier and outcomes (Sobel's P<0.001).

Conclusion: While minimizing OTP remains important, PT exerts a greater influence on outcomes after EVT. Procedural efficiency should be emphasized in stroke systems of care and included in center performance metrics to improve patient outcomes.

Keywords: Angiography; Blood Flow; Brain; Reperfusion; Stroke.

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Conflict of interest statement

Competing interests: JAG: Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst, Consultant: Cognition, Imperative Care. AA: Consultant for Cerenovus. ME: Consultant for Viz.ai and Imperative care. Investments in Galaxy Therapeutics. ASA: consultant for Balt, Johnson and Johnson, Leica, Medtronic, MicroVention, Penumbra, Scientia, Siemens, and Stryker; received research support from Cerenovus, MicroVention, Penumbra, and Siemens; and is a shareholder for Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity,Synchron, Triad Medical, and Vascular Simulations. JM: Consulting Stryker, Imperative Care Site PI EVERRUN2, STAR, RESCUE ICAS, SUCCESS, IMPERATIVE Trial, CHESS, STEP Grants Bee Foundation, Joe Niekro Foundation, Mizuho DSMB FEAT, TESTED. CM: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. Speaker for Penumbra and Silk Road Medical. Contact PI for NIH Grant R21NS128641. IM: speakers honoraria from Pfizer and Bristol-Myers Squibb. MSP: Consultant for Medtronic. AMS: consultant for Penumbra, MicroVention, and PulsarVascular; and has received travel grants/honoraria from Penumbra, Pulsar Vascular, MicroVention, and Stryker. ML: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. RG: Consultant for Balt Neurovascular, Cerenovus, Medtronic Neurovascular, Rapid Medical, and Stryker Neurovascular. MNP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Grants for the DISTAL trial from Stryker Neurovascular Inc., Phenox GmbH, Penumbra Inc. and Rapid Medical Inc., Sponsor-PI SPINNERS trial (Funded by a Siemens Healthineers AG Grant), Research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. RMS: RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. EAS: Consults for Medtronic, microvention, Rapid Medical. OT: Consulting Agreements: Viz.AI, Inc., Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Qíapel Inc, Steinberg Foundation. DGR: Consulting Agreements: Viz.AI, Inc., Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Qíapel Inc, Steinberg Foundation. PN: Consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. HHC: Consultant for Medtronic and Microvention. KL: Consultant for Medtronic and Scientia Vascular. WB: Holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. RW: Consultant for Medtronic, Stryker, and Synaptive Medical. DA: Consultant for MicroVention, Stryker, Q’apel, Synchron, and Cerenovus, Investor Von Vascular, Research Support The Bee Foundation. ARP: Consulting agreements with Microvention, Medtronic, Penumbra, IRRAS, NICO. PK: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens. Consultant for Imperative Care and Stryker Neurovascular. Stock ownership in Vena Medical. SAC: Consultant and proctor for Medtronic and Microvention. AMS: Consultant for Penumbra, Terumo. AMA: Research support from Department of Defense, Abbott Inc.

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Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Affiliations

Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Authors

Affiliations

Abstract

Conflict of interest statement

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