Impact of off-hour endovascular therapy on outcomes for acute ischemic stroke: insights from STAR

Outcomes of patients with acute ischemic stroke associated with large vessel occlusion admitted during regular and off-hours: a sub-analysis of the RESCUE-Japan Registry 2

BACKGROUND

Off-hour admissions can adversely affect clinical outcomes, though evidence in patients with acute ischemic stroke (AIS) associated with large vessel occlusion (LVO) remains limited. This study aimed to examine the impact of off-hour versus regular-hour admissions on outcomes in patients with AIS associated with LVO.

METHODS

Data from the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism (RESCUE)-Japan Registry 2, a prospective multicenter registry of patients with AIS associated with LVO were used. Eligible patients were aged ≥20 years and admitted within 24 hours of stroke onset. Off-hour admissions were defined as those occurring between 17:00 and 09:00 on weekdays and at all times on holidays, reflecting typical periods of reduced healthcare staffing. The primary outcome was a modified Rankin Scale score of 0-2, assessed 90 days post-admission.

RESULTS

Of the 2390 patients, 1794 (71.7%) and 676 (28.3%) were admitted during off-hours and regular hours, respectively. Intravenous recombinant tissue-type plasminogen activator was administered to 617 (36.0%) off-hour patients and 336 (49.7%) regular-hour patients (P<0.0001). Endovascular therapy was provided to 915 (53.4%) off-hour patients and 361 (53.4%) regular-hour patients (P=0.99). Favorable outcomes (mRS score 0-2) were observed in 604 (35.2%) off-hour patients and 272 (40.2%) regular-hour patients (P=0.02). Multivariate logistic regression analysis showed no significant difference in the primary outcome between groups (adjusted OR 1.07; 95% CI 0.84 to 1.35; P=0.56).

CONCLUSION

These findings suggest that off-hour and regular-hour admissions have similar clinical outcomes in patients with AIS associated with LVO in this Japanese cohort.

Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes

BACKGROUND AND OBJECTIVES

Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes.

METHODS

This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 pm and 7 am , with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 pm and 7 am , with other times classified as on-hours.

RESULTS

This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes.

CONCLUSION

Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.

Influence of Time of Admission on Endovascular Thrombectomy (EVT): Comparison of Outcomes During Business Hours Versus Off-Business Hours

Purpose:To investigate the differences in endovascular thrombectomy (EVT) outcomes of patients treated for acute ischaemic stroke (AIS) during business versus off-business hours. Methods: A single-centre retrospective cohort study of patients with AIS treated with EVT from February 1, 2015, to May 31, 2021, was performed at a comprehensive stroke centre (CSC). Patients were divided into business (Monday to Friday, 8 AM-5 PM) versus off-business hours groups. The primary outcome was functional neurological disability, scored using the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included the rate of successful reperfusion and procedural workflow time delays. Differences in proportions were assessed using Fisher's exact and Chi-Square tests as appropriate. For continuous variables, differences in medians between groups were assessed using Mann-Whitney U tests. Results: A total of 676 patients were included, with 399 patients (59%) comprising the off-business-hour group. No significant differences were seen in age, sex, ASPECTS score, or NIHSS at arrival. Off-business hours strokes had a longer delay between CSC arrival to groin puncture (minutes: 81 vs 44, P < .0001) and between imaging to groin puncture (minutes: 67 vs 32, P < .0001) compared to the business hours strokes. There were no differences in the rate of successful reperfusion (mTICI ≥2b) between groups (82% vs 83%, P = .61). At 90 days, 65% of patients in both groups had an mRS ≤2 (P = .91). Conclusion: Despite workflow delays in initiating EVT during off-business hours, there were no differences in the rate of successful reperfusion or functional outcomes.

Impact of Off-Hour Admission on In-Hospital Outcomes for Patients With Stroke Receiving Reperfusion Therapy in China

BACKGROUND

The structure and staffing of hospitals greatly impact patient outcomes, with frequent changes occurring during nights and weekends. This retrospective cohort study assessed the impact of admission timing on in-hospital management and outcomes for patients with stroke receiving reperfusion therapy in China using data from a nationwide registry.

METHODS

Data from patients receiving reperfusion therapy were extracted from the Chinese Stroke Center Alliance. Hospital admission time was categorized according to day/evening versus night and weekday versus weekend. Primary outcomes were in-hospital death or discharge against medical advice, hemorrhage transformation, early neurological deterioration, and major adverse cardiovascular events. Logistic regression was performed to compare in-hospital management performance and outcomes based on admission time categories.

RESULTS

Overall, 42 381 patients received recombinant tissue-type plasminogen activator (r-tPA) therapy, and 5224 underwent endovascular treatment (EVT). Patients admitted during nighttime had a higher probability of receiving r-tPA therapy within 4.5 hours from onset or undergoing EVT within 6 hours from onset compared with those admitted during day/evening hours (adjusted odds ratio, 1.04 [95% CI, 1.01-1.08]; P=0.021; adjusted odds ratio, 1.72 [95% CI, 1.59-1.86]; P<0.001, respectively). However, no significant difference was observed between weekend and weekday admissions for either treatment. No notable differences were noted between weekends and weekdays or nighttime and daytime periods in door-to-needle time for r-tPA or door-to-puncture time for EVT initiation. Furthermore, weekend or nighttime admission did not have a significant effect on the primary outcomes of r-tPA therapy or EVT. Nevertheless, in patients undergoing EVT, a higher incidence of pneumonia was observed among those admitted at night compared with those admitted during day/evening hours (adjusted odds ratio, 1.22 [95% CI, 1.05-1.42]; P=0.011).

CONCLUSIONS

Patients admitted at nighttime were more likely to receive r-tPA therapy or EVT within the time window recommended in the guidelines. However, patients receiving EVT admitted at night had an increased risk of pneumonia.

Intraoperative intensive blood pressure management strategy and the outcome of patients who had an acute ischaemic stroke undergoing endovascular treatment under general anaesthesia: study protocol for a prospective randomised controlled trial

BackgroundEndovascular thrombectomy is the recommended treatment for acute ischaemic stroke, but the optimal blood pressure management strategy during the procedure under general anaesthesia remains controversial. In this study protocol, we propose an intraoperative intensive blood pressure range (110-140 mm Hg systolic blood pressure) based on a retrospective analysis and extensive literature review. By comparing the outcomes of patients who had an acute ischaemic stroke undergoing mechanical thrombectomy under general anaesthesia with standard blood pressure management (140-180 mm Hg systolic blood pressure) versus intensive blood pressure management, we aim to determine the impact of intraoperative intensive blood pressure management strategy on patient prognosis.

METHODS AND ANALYSIS

The study is a double-blinded, randomised, controlled study, with patients randomised into either the standard blood pressure management group or the intensive blood pressure management group. The primary endpoint of the study will be the sequential analysis of modified Rankin Scale scores at 90 days after mechanical thrombectomy.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of Shanghai Changhai Hospital with an approval number CHEC2023-015. The results of the study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300070764.

Predictors of Endovascular Treatment Procedural Complications in Acute Ischemic Stroke: A Single-Center Cohort Study

BACKGROUND AND PURPOSE

Procedural complications occur in 4%-29% of endovascular treatments in acute ischemic stroke. However, little is known about their predictors and clinical impact in the real world. We aimed to investigate the frequency and clinical impact of procedural complications of endovascular treatment and identify associated risk factors.

MATERIALS AND METHODS

From 2015-2019, we retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours included in the Acute STroke Registry and Analysis of Lausanne. We identified patients having an endovascular treatment procedural complication (local access complication, arterial perforation, dissection or vasospasm, and embolization in a previously nonischemic territory) and performed logistic regression analyses to identify associated predictors. We also correlated procedural complications with long-term clinical outcome.

RESULTS

Of the 684 consecutive patients receiving endovascular treatment, 113 (16.5%) had at least 1 procedural complication. The most powerful predictors were groin puncture off-hours (OR = 2.24), treatment of 2 arterial sites (OR = 2.71), and active smoking (OR = 1.93). Patients with a complication had a significantly less favorable short-term clinical outcome (Δ-NIHSS score of -2.2 versus -4.33, P-value adjusted < .001), but a similar long-term clinical outcome (mRS at 3 months = 3 versus 2, P-value adjusted = .272).

CONCLUSIONS

Procedural complications are quite common in endovascular treatment and lead to a less favorable short-term but similar long-term outcome. Their association with treatment off-hours and at 2 arterial sites requires particular attention in these situations to optimize the overall benefit of endovascular treatment.

Workflow Intervals and Outcomes of Endovascular Treatment for Acute Large-Vessel Occlusion During On-Vs. Off-hours in China: The ANGEL-ACT Registry

Background: There may be a delay in or a poor outcome of endovascular treatment (EVT) among acute ischemic stroke (AIS) patients with large-vessel occlusion (LVO) during off-hours. By using a prospective, nationwide registry, we compared the workflow intervals and radiological/clinical outcomes between patients with acute LVO treated with EVT presenting during off- and on-hours.

Methods: We analyzed prospectively collected Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) data. Patients presenting during off-hours were defined as those presenting to the emergency department from Monday to Friday between 17:30 and 08:00, on weekends (from 17:30 on Friday to 08:00 on Monday), and on national holidays. We used logistic regression models with adjustment for potential confounders to determine independent associations between the time of presentation and outcomes.

Results: Among 1,788 patients, 1,079 (60.3%) presented during off-hours. The median onset-to-door time and onset-to-reperfusion time were significantly longer during off-hours than during on-hours (165 vs. 125 min, P = 0.002 and 410 vs. 392 min, P = 0.027). The rates of successful reperfusion and symptomatic intracranial hemorrhage were similar in both groups. The adjusted odds ratio (OR) for the 90-day modified Rankin Scale score was 0.892 [95% confidence interval (CI), 0.748–1.064]. The adjusted OR for the occurrence of functional independence was 0.892 (95% CI, 0.724–1.098), and the adjusted OR for mortality was 1.214 (95% CI, 0.919–1.603).

Conclusions: Off-hours presentation in the nationwide real-world registry was associated with a delay in the visit and reperfusion time of EVT in patients with AIS. However, this delay was not associated with worse functional outcomes or higher mortality rates.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.

Investigating the "Weekend Effect" on Outcomes of Patients Undergoing Endovascular Mechanical Thrombectomy for Ischemic Stroke

OBJECTIVES

With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT.

METHODS

This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes.

RESULTS

We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS.

CONCLUSION

These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

Background and purpose

Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry.

Methods

AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00–7:59 on weekdays) and on-hour (8:00–17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0–2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors.

Results

Of all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: −21.56; 95% CI −39.96 to −3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group.

Conclusions

The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.

Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO).

AIM

This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours.

SUMMARY OF REVIEW

Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I²= 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I²= 0%).

CONCLUSIONS

Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.