Mechanical thrombectomy for in-hospital versus community-onset ischemic stroke: comparison of time metrics, technical and clinical outcomes

Abstract

Objective: Intra-arterial thrombectomy (IAT) for in-hospital onset ischemic stroke with large vessel occlusion (LVO) is not uncommon. In-patient delay to timely neuroimaging and intervention is a reported phenomenon, but no local study on this specific issue is available. We aimed to analyze the technical and clinical outcomes of in-hospital stroke (IHS) patients with IAT performed, compared to the community-onset group (COS). Method: A retrospective 5-year data analysis was performed for 240 consecutive IATs done at Queen Mary Hospital from January 2016 to June 2021. They were dichotomized into the in-hospital and community-onset subgroups. Independent variables, such as baseline demographics, presenting NIHSS, ASPECTS, location of occlusion and thrombectomy device used, were collected. Primary outcome was functional independence (mRS 0-2) at 3 months. Secondary outcomes included onset-to-puncture time, CT-to-CTA (angiogram) time, onset-to-perfusion time, rates of successful reperfusion (TICI 2b/3), significant intracerebral hemorrhage (sICH) and 6-month mortality. These outcomes were compared with the COS cohort. Result: Among the IATs performed, 21% (50/240) were for in-hospital stroke. 38% (19/50) occurred peri-procedurally (within 14 days post-intervention). The rate of intravenous tissue plasminogen activator (IV-tPA) administration was lower (22% vs 48%, P<0.001) in the IHS group. The mean onset-to-puncture (297 vs 247 min, P=0.041) and onset-reperfusion time (379 vs 314 min, P=0.009) were significantly longer in the IHS group. The 3-month mRS 0-2 rate (40% vs 41%, P=0.91), successful reperfusion rate (84% vs 86%, P=0.85), 6-month mortality (31% vs 27%, P=0.71) and sICH (2% vs 5%, P=0.69) were similar. Conclusion:There were significant time latencies in the management of in-hospital onset LVOs. This may represent missed opportunities in the management of hyperacute stroke. Pre-specified pathways and revolutions in workflow sequence are needed to close the gap with community-onset LVOs.