Regenhardt Robert W, Nolan Neal M, Rosenthal Joseph A, McIntyre Joyce A, Bretzner Martin, Bonkhoff Anna K, Snider Samuel B, Das Alvin S, Alotaibi Naif M, Vranic Justin E, Dmytriw Adam A, Stapleton Christopher J, Patel Aman B, Rost Natalia S, Leslie-Mazwi Thabele M
Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114.
Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114.
Clin Neuroradiol. 2022 Dec;32(4):979-986. doi: 10.1007/s00062-022-01165-y. Epub 2022 Apr 29.
Given the efficacy of endovascular thrombectomy (EVT), optimizing systems of delivery is crucial. Magnetic resonance imaging (MRI) is the gold standard for evaluating tissue viability but may require more time to obtain and interpret. We sought to identify determinants of arrival-to-puncture time for patients who underwent MRI-based EVT selection in a real-world setting.
Patients were identified from a prospectively maintained database from 2011-2019 that included demographics, presentations, treatments, and outcomes. Process times were obtained from the medical charts. MRI times were obtained from time stamps on the first sequence. Linear and logistic regressions were used to infer explanatory variables of arrival-to-puncture times and effects of arrival-to-puncture time on functional outcomes.
In this study 192 patients (median age 70 years, 57% women, 12% non-white) underwent MRI-based EVT selection. 66% also underwent computed tomography (CT) at the hub before EVT. General anesthesia was used for 33%. Among the entire cohort, the median arrival-to-puncture was 102 min; however, among those without CT it was 77 min. Longer arrival-to-puncture times independently reduced the odds of 90-day good outcome (∆mRS ≤ 2 from pre-stroke, aOR = 0.990, 95%CI = 0.981-0.999, p = 0.040) when controlling for age, NIHSS, and good reperfusion (TICI 2b-3). Independent determinants of longer arrival-to-puncture were CT plus MRI (β = 0.205, p = 0.003), non-white race/ethnicity (β = 0.162, p = 0.012), coronary disease (β = 0.205, p = 0.001), and general anesthesia (β = 0.364, p < 0.0001).
Minimizing arrival-to-puncture time is important for outcomes. Real-world challenges exist in an MRI-based EVT selection protocol; avoiding double imaging is key to saving time. Racial/ethnic disparities require further study. Understanding variables associated with delay will inform protocol changes.
鉴于血管内血栓切除术（EVT）的疗效，优化输送系统至关重要。磁共振成像（MRI）是评估组织活力的金标准，但获取和解读可能需要更多时间。我们试图确定在现实环境中接受基于MRI的EVT选择的患者从到达至穿刺时间的决定因素。
从2011年至2019年前瞻性维护的数据库中识别患者，该数据库包括人口统计学、临床表现、治疗和结局。过程时间从病历中获取。MRI时间从第一个序列的时间戳中获取。使用线性和逻辑回归来推断到达至穿刺时间的解释变量以及到达至穿刺时间对功能结局的影响。
在本研究中，192例患者（中位年龄70岁，57%为女性，12%为非白人）接受了基于MRI的EVT选择。66%的患者在EVT前还在中心进行了计算机断层扫描（CT）。33%的患者使用了全身麻醉。在整个队列中，中位到达至穿刺时间为102分钟；然而，在未进行CT检查的患者中，该时间为77分钟。在控制年龄、美国国立卫生研究院卒中量表（NIHSS）和良好再灌注（脑梗死溶栓分级2b - 3级）时，较长的到达至穿刺时间独立降低了90天良好结局的几率（与卒中前相比改良Rankin量表评分≤2，校正比值比=0.990，95%置信区间=0.981 - 0.999，p = 0.040）。到达至穿刺时间较长的独立决定因素包括CT加MRI（β = 0.205，p = 0.003）、非白人种族/族裔（β = 0.162，p = 0.012）、冠状动脉疾病（β = 0.205，p = 0.001）和全身麻醉（β = 0.364，p < 0.0001）。
尽量缩短到达至穿刺时间对结局很重要。基于MRI的EVT选择方案存在现实挑战；避免重复成像对于节省时间至关重要。种族/族裔差异需要进一步研究。了解与延迟相关的变量将为方案改变提供依据。
