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Original Investigation
January 22, 2019

Association of Time From Stroke Onset to Groin Puncture With Quality of Reperfusion After Mechanical Thrombectomy: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials

Author Affiliations
  • 1Centre Hospitalier Universitaire de Nantes, Nantes Cedex, France
  • 2University of Calgary, Calgary, Alberta, Canada
  • 3University of California, Los Angeles Medical Center, Los Angeles
  • 4University of Glasgow, Glasgow, Scotland
  • 5State University of New York at Buffalo
  • 6Erasmus MC, University Medical Center, Rotterdam, the Netherlands
  • 7Academic Medical Center Amsterdam, Amsterdam, the Netherlands
  • 8Maastricht University Medical Center, Maastricht, the Netherlands
  • 9University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 10The Royal Melbourne Hospital, Victoria, Australia
  • 11University Hospital of Montpellier, Montpellier, France
  • 12The Florey Institute of Neuroscience and Mental Health, Parkville, Australia
  • 13Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  • 14University Hospital of Poitiers, Poitiers, France
  • 15Department Radiology, MC Haaglanden, Leidschendam, the Netherlands
  • 16Hopital Saint Anne, University Paris-Descartes, Paris, France
  • 17Department of Neuroradiology, Royal Victoria Hospital, Belfast, Belfast, Ireland
  • 18Altair Biostatistics, Mooresville, North Carolina
  • 19Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
  • 20University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
  • 21Abington and Jefferson Health, Abington, Pennsylvania
  • 22University of Duisburg-Essen, Duisburg-Essen, Germany
  • 23Oxford University Hospitals National Health Services Foundation trust and University of Oxford, Oxford, England
  • 24Hospital Vall d'Hebron, Barcelona, Spain
  • 25Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, England
  • 26Department of Clinical Neuroscience, Central Clinical School, Monash University and The Alfred Hospital, Melbourne, Australia
  • 27Hospital Clinic of Barcelona, Barcelona, Spain
  • 28Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
  • 29University of Lorraine, and University Hospital of Nancy, Nancy, France
JAMA Neurol. 2019;76(4):405-411. doi:10.1001/jamaneurol.2018.4510
Key Points

Question  Is the quality of reperfusion rated with the thrombolysis in cerebral infarction score associated with longer hospital arrival to groin puncture time?

Findings  In this meta-analysis, the rate of successful reperfusion, defined as a thrombolysis in cerebral infarction score of 2b-3 at the end of the procedure, decreased as time elapsed after arrival at the stroke endovascular center.

Meaning  Fast reperfusion is a major modifiable factor associated with better clinical outcome when successful reperfusion is achieved, and the intermediary outcome, the rate of successful reperfusion, is higher with faster in-hospital process times.


Importance  Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. However, data are scarce on the association between the time from onset and reperfusion results.

Objective  To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS.

Design, Setting, and Participants  We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015.

Main Outcomes and Measures  Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression.

Results  Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture.

Conclusions and Relevance  Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.