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Original Investigation
September 27, 2016

Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis

Author Affiliations
  • 1David Geffen School of Medicine, University of California-Los Angeles, Los Angeles
  • 2University of Calgary, Calgary, Alberta, Canada
  • 3Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
  • 4Academic Medical Center, Amsterdam, the Netherlands
  • 5University of Melbourne, Melbourne, Australia
  • 6Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
  • 7Hospital Vall d'Hebron, Barcelona, Spain
  • 8Hospital de Bellvitge, L'Hospet de Llobregat, Barcelona, Spain
  • 9Erlanger Hospital at the University of Tennessee, Chattanooga
  • 10Swedish Medical Center, Englewood, Colorado
  • 11Klinikum der Goethe–Universität, Frankfurt, Germany
  • 12University of Pittsburgh Medical Center, Pittsburgh, Pennyslvania
  • 13State University of New York at Buffalo, Buffalo
  • 14Maastricht University Medical Center, Maastricht, the Netherlands
  • 15Hospital Germans Trias i Pujol, Barcelona, Spain
  • 16Erlanger Medical Center, Chattanooga, Tennessee
  • 17Hospital Clinic de Barcelona, Barcelona, Spain
  • 18University Health Network, Toronto, Ontario, Canada
  • 19Florey Institute, Melbourne, Australia
  • 20University of Alberta, Edmonton, Alberta, Canada
  • 21Altair Biostatistics, St Louis Park, Minnesota
  • 22Philadelphia College of Osteopathic Medicine, Philadelphia, Pennyslvania
JAMA. 2016;316(12):1279-1289. doi:10.1001/jama.2016.13647
Key Points

Question  What is the relation between time to treatment and outcome from endovascular mechanical thrombectomy for acute ischemic stroke?

Findings  In this meta-analysis of pooled individual patient data from 1287 adults in 5 randomized trials, compared with medical therapy alone, thrombectomy up to 7.3 hours after symptom onset was associated with improved outcomes. Rates of functional independence after thrombectomy were 64% with reperfusion at 3 hours vs 46% with reperfusion at 8 hours.

Meaning  In acute ischemic stroke due to large-vessel occlusion, endovascular mechanical thrombectomy should be initiated as soon as possible within the first 7 hours after symptom onset.


Importance  Endovascular thrombectomy with second-generation devices is beneficial for patients with ischemic stroke due to intracranial large-vessel occlusions. Delineation of the association of treatment time with outcomes would help to guide implementation.

Objective  To characterize the period in which endovascular thrombectomy is associated with benefit, and the extent to which treatment delay is related to functional outcomes, mortality, and symptomatic intracranial hemorrhage.

Design, Setting, and Patients  Demographic, clinical, and brain imaging data as well as functional and radiologic outcomes were pooled from randomized phase 3 trials involving stent retrievers or other second-generation devices in a peer-reviewed publication (by July 1, 2016). The identified 5 trials enrolled patients at 89 international sites.

Exposures  Endovascular thrombectomy plus medical therapy vs medical therapy alone; time to treatment.

Main Outcomes and Measures  The primary outcome was degree of disability (mRS range, 0-6; lower scores indicating less disability) at 3 months, analyzed with the common odds ratio (cOR) to detect ordinal shift in the distribution of disability over the range of the mRS; secondary outcomes included functional independence at 3 months, mortality by 3 months, and symptomatic hemorrhagic transformation.

Results  Among all 1287 patients (endovascular thrombectomy + medical therapy [n = 634]; medical therapy alone [n = 653]) enrolled in the 5 trials (mean age, 66.5 years [SD, 13.1]; women, 47.0%), time from symptom onset to randomization was 196 minutes (IQR, 142 to 267). Among the endovascular group, symptom onset to arterial puncture was 238 minutes (IQR, 180 to 302) and symptom onset to reperfusion was 286 minutes (IQR, 215 to 363). At 90 days, the mean mRS score was 2.9 (95% CI, 2.7 to 3.1) in the endovascular group and 3.6 (95% CI, 3.5 to 3.8) in the medical therapy group. The odds of better disability outcomes at 90 days (mRS scale distribution) with the endovascular group declined with longer time from symptom onset to arterial puncture: cOR at 3 hours, 2.79 (95% CI, 1.96 to 3.98), absolute risk difference (ARD) for lower disability scores, 39.2%; cOR at 6 hours, 1.98 (95% CI, 1.30 to 3.00), ARD, 30.2%; cOR at 8 hours,1.57 (95% CI, 0.86 to 2.88), ARD, 15.7%; retaining statistical significance through 7 hours and 18 minutes. Among 390 patients who achieved substantial reperfusion with endovascular thrombectomy, each 1-hour delay to reperfusion was associated with a less favorable degree of disability (cOR, 0.84 [95% CI, 0.76 to 0.93]; ARD, −6.7%) and less functional independence (OR, 0.81 [95% CI, 0.71 to 0.92], ARD, −5.2% [95% CI, −8.3% to −2.1%]), but no change in mortality (OR, 1.12 [95% CI, 0.93 to 1.34]; ARD, 1.5% [95% CI, −0.9% to 4.2%]).

Conclusions and Relevance  In this individual patient data meta-analysis of patients with large-vessel ischemic stroke, earlier treatment with endovascular thrombectomy + medical therapy compared with medical therapy alone was associated with lower degrees of disability at 3 months. Benefit became nonsignificant after 7.3 hours.