Analysis of Workflow and Time to Treatment on Thrombectomy Outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) Randomized, Controlled Trial

Bijoy K Menon; Tolulope T Sajobi; Yukun Zhang; Jeremy L Rempel; Ashfaq Shuaib; John Thornton; David Williams; Daniel Roy; Alexandre Y Poppe; Tudor G Jovin; Biggya Sapkota; Blaise W Baxter; Timo Krings; Frank L Silver; Donald F Frei; Christopher Fanale; Donatella Tampieri; Jeanne Teitelbaum; Cheemun Lum; Dar Dowlatshahi; Muneer Eesa; Mark W Lowerison; Noreen R Kamal; Andrew M Demchuk; Michael D Hill; Mayank Goyal

doi:10.1161/CIRCULATIONAHA.115.019983

Analysis of Workflow and Time to Treatment on Thrombectomy Outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) Randomized, Controlled Trial

Circulation. 2016 Jun 7;133(23):2279-86. doi: 10.1161/CIRCULATIONAHA.115.019983. Epub 2016 Apr 13.

Authors

Bijoy K Menon¹, Tolulope T Sajobi¹, Yukun Zhang¹, Jeremy L Rempel¹, Ashfaq Shuaib¹, John Thornton¹, David Williams¹, Daniel Roy¹, Alexandre Y Poppe¹, Tudor G Jovin¹, Biggya Sapkota¹, Blaise W Baxter¹, Timo Krings¹, Frank L Silver¹, Donald F Frei¹, Christopher Fanale¹, Donatella Tampieri¹, Jeanne Teitelbaum¹, Cheemun Lum¹, Dar Dowlatshahi¹, Muneer Eesa¹, Mark W Lowerison¹, Noreen R Kamal¹, Andrew M Demchuk¹, Michael D Hill¹, Mayank Goyal²

Affiliations

¹ From Department of Clinical Neurosciences and Radiology (B.K.M., T.T.S., M.E., N.R.K., A.M.D, M.D.H., M.G.) andDepartment of Community Health Sciences (B.K.M., Y.Z., A.M.D.,M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Canada; Departments of Radiology (J.L.R.) and Medicine (A.S.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J.T.) andGeriatric and Stroke Medicine(D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), University of Montreal, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services, University of Tennessee, Chattanooga (B.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology (T.K.) andDivision of Neurology, Department of Medicine (F.L.S.), Toronto Western Hospital, Canada; Colorado Neurological Institute, Engelwood, CO (D.F.F., C.F.); Montreal Neurological Institute, Canada (D.T., J.T.); Departments of Radiology (C.L.) and Neurology (D.D.), University of Ottawa, Canada; Clinical Research Unit, University of Calgary, Canada (M.W.L.); and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., T.T.S., M.E., A.M.D., M.D.H., M.G.).
² From Department of Clinical Neurosciences and Radiology (B.K.M., T.T.S., M.E., N.R.K., A.M.D, M.D.H., M.G.) andDepartment of Community Health Sciences (B.K.M., Y.Z., A.M.D.,M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Canada; Departments of Radiology (J.L.R.) and Medicine (A.S.), University of Alberta, Edmonton, Canada; Departments of Neuroradiology (J.T.) andGeriatric and Stroke Medicine(D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin; Departments of Radiology (D.R.) and Neurosciences (A.Y.P.), University of Montreal, Canada; Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.); Acute Stroke Services, University of Tennessee, Chattanooga (B.S.); Department of Radiology, Erlanger Hospital, University of Tennessee, Chattanooga (B.W.B.); Division of Radiology (T.K.) andDivision of Neurology, Department of Medicine (F.L.S.), Toronto Western Hospital, Canada; Colorado Neurological Institute, Engelwood, CO (D.F.F., C.F.); Montreal Neurological Institute, Canada (D.T., J.T.); Departments of Radiology (C.L.) and Neurology (D.D.), University of Ottawa, Canada; Clinical Research Unit, University of Calgary, Canada (M.W.L.); and Hotchkiss Brain Institute, Calgary, Canada (B.K.M., T.T.S., M.E., A.M.D., M.D.H., M.G.). mgoyal@ucalgary.ca.

PMID: 27076599
DOI: 10.1161/CIRCULATIONAHA.115.019983

Abstract

Background: The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital, and health system characteristics on workflow within the trial.

Methods and results: Relationship between outcome (modified Rankin Scale) and interval times was modeled by using logistic regression. Association between time intervals (stroke onset to arrival in endovascular-capable hospital, to qualifying computed tomography, to groin puncture, and to reperfusion) and patient, hospital, and health system characteristics were modeled by using negative binomial regression. Every 30-minute increase in computed tomography-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90-day modified Rankin Scale 0-2) by 8.3% (P=0.006). Symptom onset-to-imaging time was not associated with outcome (P>0.05). Onset-to-endovascular hospital arrival time was 42% (34 minutes) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) versus direct transfer (mothership). Computed tomography-to-groin puncture time was 15% (8 minutes) shorter among patients presenting during work hours versus off hours, 41% (24 minutes) shorter in drip-ship patients versus mothership, and 43% (22 minutes) longer when general anesthesia was administered. The use of a balloon guide catheter during endovascular procedures shortened puncture-to-reperfusion time by 21% (8 minutes).

Conclusions: Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, use of general anesthesia, and endovascular techniques offer major opportunities for improvement in workflow.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.

Keywords: cerebrovascular disorders; emergency treatment; endovascular procedures; stroke; thrombolytic therapy.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Administration, Intravenous
After-Hours Care
Anesthesia, General
Brain Ischemia / diagnostic imaging
Brain Ischemia / mortality
Brain Ischemia / therapy*
Cerebral Angiography / methods
Computed Tomography Angiography
Disability Evaluation
Endovascular Procedures* / adverse effects
Endovascular Procedures* / mortality
Fibrinolytic Agents / administration & dosage
Humans
Predictive Value of Tests
Punctures
Risk Factors
Stroke / diagnostic imaging
Stroke / mortality*
Stroke / therapy*
Thrombectomy* / adverse effects
Thrombectomy* / mortality
Thrombolytic Therapy* / adverse effects
Thrombolytic Therapy* / mortality
Time Factors
Time and Motion Studies*
Time-to-Treatment*
Tissue Plasminogen Activator / administration & dosage
Treatment Outcome
Triage
Workflow*

Substances

Fibrinolytic Agents
Tissue Plasminogen Activator

Associated data

ClinicalTrials.gov/NCT01778335

Grants and funding

CIHR/Canada