Neurointervention.  2018 Mar;13(1):2-12. 10.5469/neuroint.2018.13.1.2.

Temporal Changes in Care Processes and Outcomes for Endovascular Treatment of Acute Ischemic Stroke: Retrospective Registry Data from Three Korean Centers

Affiliations
  • 1Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, Korea.
  • 2Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, Korea.
  • 3Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea. sungil.sohn@gmail.com
  • 4Department of Radiology, Keimyung University Dongsan Medical Center, Daegu, Korea.
  • 5Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, Korea.
  • 6Department of Neurology, Kyungpook National University School of Medicine and Hospital, Daegu, Korea. yangha.hwang@gmail.com
  • 7Department of Radiology, Kyungpook National University School of Medicine and Hospital, Daegu, Korea.
  • 8Department of Neurosurgery, Kyungpook National University School of Medicine and Hospital, Daegu, Korea.
  • 9Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
  • 10Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada.

Abstract

BACKGROUND AND PURPOSE
The purpose of the current study is to evaluate the influence of temporal patterns related to the availability of new endovascular treatment (EVT) devices on care processes and outcomes among patients with AIS.
MATERIALS AND METHODS
We enrolled 720 consecutive patients (January 2011 to May 2016) in a retrospective registry, ASIAN KR, from three Korean hospitals, who received EVT for acute ischemic stroke (AIS) caused by cervicocephalic arterial occlusions. We performed period-to-period analyses based on stent retriever reimbursement and the availability of second-generation direct-aspiration devices (Period 1: January 2011-July 2014 vs. Period 2: August 2014-May 2016); time metrics and outcomes were compared when the onset-to-puncture time was <720 min among patients with EVT for intracranial occlusion.
RESULTS
Period 2 had better post-EVT outcomes (3-month modified Rankin Scale 0-2 or equal to prestroke score, 48.3% vs. 60.2%, P=0.004), more successful reperfusion rates (modified Treatment In Cerebral Ischemia 2b-3, 74.2% vs. 82.2%, P=0.019), fewer subarachnoid hemorrhages (modified Fisher grade 3-4, 5.5% vs. 2.0%, P=0.034) and lower hemorrhagic transformation rates (any intracerebral hemorrhage, 35.3 vs. 22.7%, P=0.001) than Period 1. Compared to Period 1, Period 2 had a shorter door-to-puncture time (median 109 vs. 90 min, P<0.001), but longer onset-to-door time (129 vs. 143 min, P=0.057).
CONCLUSION
Recent temporal improvements in post-EVT AIS outcomes in Korea are likely due to a combination of enhanced hospital care processes and administration of newer thrombectomy devices.

Keyword

Cerebral infarction; Thrombectomy; Reperfusion; Cerebral hemorrhage; Learning curve; Treatment outcome

MeSH Terms

Asian Continental Ancestry Group
Brain Ischemia
Cerebral Hemorrhage
Cerebral Infarction
Humans
Korea
Learning Curve
Reperfusion
Retrospective Studies*
Stents
Stroke*
Subarachnoid Hemorrhage
Thrombectomy
Treatment Outcome

Figure

  • Fig. 1 Annual trends in intervention method. (A) The total number of endovascular treatment (EVT) cases increased annually at the three centers. The white bar indicates EVT cases performed in 2016 that were not included in the ASIAN KR registry. (B) The use of the direct-aspiration system remained similar throughout the study period. (C) The use of the stent retriever system rapidly increased over the study period. (D) The use of balloon guide catheters increased over the study period.

  • Fig. 2 Outcomes per year. (A) The reperfusion grade improved annually throughout the study period (P < 0.001). Complete reperfusion improved considerably in the last 2 years. (B) Clinical outcomes are in line with the reperfusion grade. The percentage of good outcomes progressively improved over the last 3 years (P = 0.097).

  • Fig. 3 Relationship of onset-to-puncture time and good outcome (modified Rankin Scale score 0–2 at 3 months). The probability of good outcomes was similarly reduced until around 400 minutes of onset-to-puncture time; however, the declining tendency appeared to be steeper in period 1 compared to period 2 after 400 minutes.

  • Fig. 4 Summary and highlights of the current study. (A) Launches of thrombectomy devices in Korea, presentation of new RCTs overseas, and temporal improvement in endovascular treatment outcomes between period 1 and 2 in the current study. (B) Outcome-improving factors among patients with acute ischemic stroke due to intracranial large artery occlusion who underwent endovascular reperfusion treatment. To summarize the current study, better outcomes were related to fast in-hospital care systems, as represented by reduced door-to-puncture times, and low hemorrhagic complication rates, which resulted from physicians' experiences and the use of new, high-performance devices. Although factors regarding patient selection were not specified in the current study, appropriate patient selection might widen the therapeutic time window without negatively affecting the clinical outcomes. RCT, randomized control trial; [A], approved; [R], reimbursed; ER, emergency room.


Cited by  3 articles

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Je Hong Min, Seong-Joon Lee, Ji Man Hong, Jin Wook Choi, Dong-Hun Kang, Yong-Won Kim, Yong-Sun Kim, Jeong-Ho Hong, Joonsang Yoo, Chang-Hyun Kim, Sung-Il Sohn, Yang-Ha Hwang, Jin Soo Lee
Neurointervention. 2019;14(2):107-115.    doi: 10.5469/neuroint.2019.00108.

Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population
Jin Soo Lee, Yang-Ha Hwang, Sung-Il Sohn
Neurointervention. 2021;16(2):91-110.    doi: 10.5469/neuroint.2020.00339.

Primary neurocritical care involving therapeutic hypothermia for acute ischemic stroke patients with malignant infarct cores
Seong-Joon Lee, Kyu Sun Lee, Jin Soo Lee, Mun Hee Choi, Sung Eun Lee, Ji Man Hong
J Neurocrit Care. 2019;12(1):30-36.    doi: 10.18700/jnc.190076.


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