Abstract DP336: Thrombectomy Utilization and Outcomes for Patients with Large Vessel Occlusions Presenting After 24 Hours

Stroke · 2026-01-29

Introduction: Thrombectomy is established as standard of care for select patients with an acute large vessel occlusion (LVO) up to 24 hours from last known normal (LKN) based on randomized trial inclusion criteria. The benefit of intervention after 24 hours has not been established and there are limited data on thrombectomy utilization in this time window in current practice. We aimed to describe the proportion of patients receiving thrombectomy in this very late window and to compare their clinical outcomes to patients treated earlier. Methods: Using American Heart Association/American Stroke Association Get With The Guidelines-Stroke registry data, we identified patients presenting to a Comprehensive or Thrombectomy-Capable Stroke Center with an internal carotid, M1, or M2 occlusion and NIHSS ≥6. Using generalized estimating equations adjusted for patient- and hospital-level characteristics, the odds of thrombectomy, discharge functional independence (modified Rankin 0–2), and ambulatory status among those arriving >23.5 hours after LKN were compared to those arriving within 5.5–23.5 hours. Results: Between January 1, 2018, and June 30, 2024, there were 39,427 patients with an ischemic stroke presenting between 23.5–48 hours, of which 3,373 (8.6%) had a proximal anterior LVO with NIHSS ≥6. Of these LVO patients, 1,789 (53.0%) underwent thrombectomy. In contrast, 24,409 of 34,163 LVOs (71.4%) arriving 5.5–23.5 hours after LKN received thrombectomy. Patients arriving after 23.5 hours were predominantly similar in patient and hospital characteristics including age and stroke severity (Table). Compared to patients receiving thrombectomy within 5.5–23.5 hours, patients treated after > 23.5 hours were less likely to be functionally independent (OR 0.70 [0.60–0.82], p<0.001) and ambulating independently (OR 0.73 [0.64–0.83], p<0.001). The incidence of symptomatic hemorrhage in patients treated >23.5 hours was 5.5%, compared to 6.9% in patients treated between 5.5–23.5 hours (p=0.546). Conclusions: In this largest ever analysis of late-presenting LVOs, patients presenting >23.5 hours after LKN were less likely to undergo thrombectomy compared to patients arriving earlier. The odds of independent ambulation and functional independence at hospital discharge were also reduced compared to patients presenting earlier, despite similar safety. Prospective clinical trials are needed to determine whether very late thrombectomy improves outcomes.

Abstract DP276: Association Between Time to Thrombectomy and Functional Outcomes Up To 24 Hours After Last Known Well

Stroke · 2026-01-29

Introduction: Endovascular thrombectomy (EVT) has proven benefit for select patients with acute stroke due to large vessel occlusion (LVO) within 24 hours of last known well (LKW). Randomized trials have shown a declining benefit of EVT within the first 6 hours, but no clear reduction in benefit after 6 hours when patients are selected by advanced imaging. We aimed to examine the association between time from LKW to EVT and outcomes in clinical practice. Methods: Using the American Heart Association/American Stroke Association Get With The Guidelines-Stroke registry data, we identified patients who underwent thrombectomy for a proximal, anterior circulation LVO at a Comprehensive or Thrombectomy-Capable Stroke Center within 24 hours of LKW. The relationships between onset (defined by LKW) to arterial puncture (OTP) time and functional outcomes at hospital discharge were quantified using generalized estimating equations adjusted for patient- and hospital-level characteristics. Results: Between January 1, 2018, and June 30, 2024, there were 41,736 patients who underwent thrombectomy within 24 hours of LKW, including 56.4% with OTP time 0–6 hours, 22.7% within 6–12 hours, 14.9% within 12–18 hours, and 6.1% within 18–24 hours. After adjustment, functional independence (defined as modified Rankin 0–2) and independent ambulation at discharge declined linearly over time (Figure 1). For each hour delay, the odds of functional independence decreased by 5.0% (95% CI, 4.4–5.5%; p<0.001) and independent ambulation decreased by 4.2% (95% CI, 3.7–4.6%; p<0.001). These associations were modified by whether symptom onset was witnessed (Figures 2 and 3). Patients with witnessed onset had an odds reduction in functional independence of 6.8% per hour (95% CI, 5.8–7.7%; p<0.001), compared to 4.1% (95% CI, 3.4–4.8%; p<0.001) with unwitnessed onset. Patients with witnessed symptom onset had 5.5% lower odds (95% CI, 4.7–6.2%; p<0.001) of independent ambulation, compared to 3.4% (95% CI, 2.8–3.9%; p<0.001) with unwitnessed onset (Figure 3). Conclusions: Earlier thrombectomy is associated with a greater likelihood of favorable outcome at hospital discharge across all timeframes, with stronger associations seen in patients with witnessed symptom onset. These results underscore the importance of reducing treatment delays to maximize the benefit of EVT in patients with LVO.

Abstract WP024: Impact of Time on Thrombectomy Utilization in Patients with Acute Stroke Due To Large Vessel Occlusion

Stroke · 2026-01-29

Introduction: Randomized controlled trials have established the benefit of thrombectomy within 24 hours of time last known normal (LKN). Studies supporting the role of thrombectomy in the 6– to 24–hour window selected patients based on favorable penumbral imaging, and it is unclear how thrombectomy eligibility and utilization change over time. We aimed to characterize changes in thrombectomy utilization within the 24-hour time window. Methods: Using data from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke registry, we identified patients with a proximal large vessel occlusion (LVO) of the intracranial internal carotid artery, M1, or M2 segments of the middle cerebral artery, and NIHSS ≥ 6 who presented directly to a Comprehensive or Thrombectomy-Capable Stroke Center between January 1, 2018, and June 30, 2024. Patients were stratified by time from LKN to vascular imaging. The odds of thrombectomy over time were modeled using generalized estimating equations adjusted for patient-level characteristics (demographics, medical history, and thrombolytic administration) and hospital-level factors (stroke center certification, geographic region, and annual thrombectomy volume). Results: Of 356,250 ischemic stroke patients presenting within 0–5.5 hours of LKN, 45,502 (12.8%) ultimately underwent thrombectomy, compared to 11,083 of 94,720 (11.7%) at 5.5–11.5 hours, 7,279 of 75,410 (9.7%) at 11.5–17.5 hours, and 2,452 of 39,035 (6.3%) at 17.5–23.5 hours. Among the 49,191 patients with NIHSS ≥6 and proximal LVO identified on vascular imaging, thrombectomy use decreased with each successive stratum of time from LKN to imaging (Figure 1). Compared to those within 0–5.5 hours, patients with LVO imaged at 5.5–11.5 hours had 32.8% (95% CI, 28.1–37.1%) lower adjusted odds of thrombectomy; those at 11.5–17.5 hours had 46.0% (95% CI, 41.7–50.0%) lower odds, and those at 17.5–23.5 hours had 66.8% (95% CI, 63.5–69.9%) lower odds (p<0.001 for all comparisons). Each hour of delay was associated with a 6.0% (95% CI, 5.5–6.4%; p<0.001) reduction in the odds of thrombectomy. The rate of decay in thrombectomy utilization did not change between 0–6 and 6–24 hours. Conclusions: Thrombectomy utilization declines linearly over the 24-hour window, which may reflect a corresponding reduction in salvageable penumbra. All efforts should be made to identify and assess stroke patients as quickly as possible to increase the likelihood of receiving treatment.

Public Reporting of Quality and Clinical Outcomes in the Get With The Guidelines–Stroke Registry

JAMA Network Open · 2026-01-12

Importance: Public reporting of outcomes increases transparency. Research on the association between public reporting programs and quality of care and outcomes is needed. Objective: To evaluate whether hospital voluntary participation in the Get With The Guidelines (GWTG)-Stroke public reporting program is associated with quality of care and clinical outcomes. Design, Setting, and Participants: This cohort study used GWTG-Stroke registry data from January 1 to December 31, 2021. Clinical characteristics associated with hospital participation in public reporting were identified, and differences in patient quality of care and outcomes were compared between hospitals that participated in public reporting of outcomes and those that did not. The primary data analysis was completed on December 27, 2024, and revised November 15, 2025. Exposure: Hospital participation in public reporting. Main Outcomes and Measures: The primary quality metric was defect-free care, a composite of 7 ischemic stroke quality measures (intravenous thrombolysis for patients arriving by 3.5 hours and treated by 4.5 hours, early antithrombotic use within 48 hours of admission, venous thromboembolism prophylaxis, antithrombotics at hospital discharge, anticoagulation for atrial fibrillation or flutter, smoking cessation counseling, and intensive statin therapy at discharge). Component measures were evaluated as secondary outcomes. The primary clinical outcome was independent ambulation at discharge. Secondary clinical outcomes included discharge to home, in-hospital mortality, and a composite of in-hospital mortality or discharge to hospice. Associations were measured using multivariable models adjusted for patient- and hospital-level variables. Results: There were 501 763 patients admitted for acute ischemic stroke (mean [SD] age, 69.8 [3.8] years; mean [SD] male, 51.5% [10.3%]) at 2423 hospitals; 1582 hospitals (65.3%) participated in public reporting. High-volume hospitals (quartile 4 [highest] vs 1 [lowest]: adjusted odds ratio [OR], 2.07 [95% CI, 1.43-2.99]) and high-performing hospitals measured by 2018 GWTG-Stroke quality awards (silver or gold: OR, 3.32 [95% CI, 2.63-4.20]) were more likely to participate in public reporting. In fully adjusted models, patients treated at participating hospitals were more likely to receive defect-free care (OR, 1.31 [95% CI, 1.27-1.35]) and more likely to receive all 7 of the individual components of defect-free care, although absolute differences between groups were small. There were minor differences in independent ambulation at discharge (OR, 1.02 [95% CI, 1.01-1.04]) and the composite of in-hospital mortality or discharge to hospice (OR, 1.05 [95% CI, 1.02-1.08]). There were no differences in discharge to home or in-hospital mortality. Conclusions and Relevance: In this cohort study of hospitals in the GWTG-Stroke program in 2021, patients at hospitals participating in voluntary public reporting were more likely to receive guideline-based care but had similar clinical outcomes compared with patients at nonreporting hospitals. More research is needed to evaluate whether public reporting could improve clinical outcomes.

General vs Nongeneral Anesthesia for Endovascular Thrombectomy in Patients With Large Core Strokes

Neurology · 2025-06-26 · 3 citations

BACKGROUND AND OBJECTIVES: The association of anesthesia approach during endovascular thrombectomy (EVT) with clinical outcomes in large strokes is unexplored. We aimed to evaluate whether general anesthesia (GA), compared with non-GA, was associated with better functional outcomes in the SELECT2 trial. METHODS: In a prespecified secondary analysis of the SELECT2 trial that enrolled patients with large strokes on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 3-5), CT perfusion/MRI (core volume ≥50 mL), or both, functional outcomes were compared in EVT-treated patients who received GA or non-GA and whether this association was modified by stroke severity (NIH Stroke Scale score), ischemic injury estimates, and collateral status was evaluated. The primary outcome was 90-day functional status (ordinal modified Rankin Scale [mRS]). Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality. RESULTS: -interaction = 0.77 and 0.89, respectively). DISCUSSION: In patients with large core strokes randomized in SELECT2, EVT outcomes did not differ significantly based on anesthesia approach (GA or non-GA) without heterogeneity across stroke severity and size. While GA was associated with higher SBP variability and lower minimum SBP, this did not modify GA association with functional outcomes. While allocation to anesthesia approach was nonrandomized, our findings suggest that optimizing institutional protocols for preferred anesthesia technique, whether GA or non-GA, may enhance EVT procedural outcomes. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov ID: NCT03876457. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that in patients presenting within 24 hours with large vessel occlusion strokes undergoing EVT, the 90-day mRS score is comparable in those with or without GA.

American Heart Association National Integrated ASCVD Initiative: An Implementation Initiative to Improve Lipid Management Among Patients With ASCVD

Circulation Cardiovascular Quality and Outcomes · 2025-08-01 · 2 citations

Effect of Weekend Admission on Hip Fracture Mortality

Ochsner Journal · 2025-01-01 · 1 citations

<h3>Background</h3> Weekend vs weekday hospital admission has been associated with poorer mortality rates for many conditions. Studies evaluating weekend admission for hip fractures have resulted in contradictory conclusions regarding outcomes. <h3>Methods</h3> We conducted a retrospective analysis of all patients who underwent surgery for a fragility hip fracture at a quaternary level teaching hospital during a 6-year period. A total of 1,164 patients were included: 796 weekday admissions (Monday through Friday) vs 368 weekend admissions (Saturday and Sunday). Patients were subdivided based on surgeon experience level (473 consultants vs 690 nonconsultants). Statistical tests included chi-square tests and logistic regression. Demographic data included age, sex, prior hip fracture, fracture type, operation, and American Society of Anesthesiologists grade. The primary outcome was 1-year mortality. Secondary outcomes were acute mortality (&lt;24 hours), subacute mortality (1 to 30 days), change in mobility from baseline at 1 year, preoperative delay (&gt;48 hours), and surgical duration. <h3>Results</h3> The weekend admission cohort had a higher 1-year mortality rate than the weekday admission cohort (30.4% vs 23.2%; <i>P</i>=0.029), while subacute mortality trended toward significance (<i>P</i>=0.083). No significant difference was seen in acute mortality (<i>P</i>=0.5). Hemiarthroplasty was associated with increased mortality at 12 months (<i>P</i>=0.012) compared to the other operative interventions. The median duration of surgery was lower in the weekend cohort vs the weekday cohort (1.15 hours [69 minutes] vs 1.23 hours [73.8 minutes]; <i>P</i>&lt;0.001). Consultants performed surgeries 16.2 minutes faster than nonconsultants (<i>P</i>&lt;0.001) and trended toward a lower 1-year mortality rate (22.1% vs 27.9%; <i>P</i>=0.058). No significant difference was seen in mobility change at 1 year in both the consultant vs nonconsultant analysis (<i>P</i>&gt;0.9) and in the weekday vs weekend analysis (<i>P</i>&gt;0.12). <h3>Conclusion</h3> A significantly increased 1-year mortality rate and a shorter surgical duration were observed among patients admitted on the weekends.

Pre-hospital LVO detection: One size does not fit all

Journal of Stroke and Cerebrovascular Diseases · 2025-04-17 · 1 citations

A range of techniques are being developed with the goal of leverage physiologic data to detect large vessel occlusion (LVO) in the prehospital setting. The output of most every technique is a continuous (or ordinal) variable, but a threshold is applied to yield a simplified binary outcome (i.e., high-likelihood LVO vs low-likelihood LVO). The mathematically optimal threshold is typically selected to balance sensitivity and specificity. Though intuitive, this approach may not appropriately account for the relative significance of false negatives and false positives. Most importantly, relying on a single threshold is an unnecessary oversimplification, and this one-size-fits-all approach to prehospital LVO detection does not optimally account for the diversity of prehospital systems of care. Here, we use a recently reported technique, optical blood flow imaging, to demonstrate how thresholds can be easily titrated in favor of sensitivity or specificity and thereby provide options that may better serve any given micro-environment.

Short-Term Safety and Effectiveness for Tenecteplase and Alteplase in Acute Ischemic Stroke

JAMA Network Open · 2025-03-12 · 10 citations

Importance: Tenecteplase is an alternative to alteplase for emergency treatment of acute ischemic stroke. However, limited data are available comparing their clinical effectiveness in routine clinical practice. Objective: To compare short-term effectiveness and safety outcomes for patients with ischemic stroke treated with intravenous tenecteplase vs alteplase. Design, Setting, and Participants: This comparative effectiveness study used data prospectively collected from July 1, 2020, through June 30, 2022, from the Get With The Guidelines-Stroke registry. Exposure: Consecutive patients with ischemic stroke treated with either tenecteplase or alteplase within 4.5 hours from last known well time were included. Main Outcomes and Measures: The primary end point was functional independence on discharge (modified Rankin Scale [mRS] score, 0-2). Secondary effectiveness end points included disability free at discharge (mRS score, 0-1), discharge home, and independent ambulation at discharge. Safety end points included symptomatic intracranial hemorrhage (sICH) within 36 hours and combined in-hospital mortality or hospice discharge. Generalized linear mixed models were fit to evaluate associations between exposure to tenecteplase (vs alteplase) and end points after adjustment for demographic, clinical, and hospital-level variables. Adjusted odds ratios (AORs) with 95% CIs were computed. Results: Among 79 550 patients treated with intravenous thrombolysis, the mean (SD) age was 68.6 (14.8) years, 38 596 (48.5%) were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 7 (IQR, 4-13). Of these patients, 9465 (11.9%) received tenecteplase (mean [SD] age, 69.6 [14.7] years; median NIHSS score, 7 [IQR, 4-14]; 4504 [47.6%] female) and 70 085 (88.1%) received alteplase (mean [SD] age, 68.5 [14.8] years; median NIHSS score, 7 [IQR, 4-13]; 34 092 [48.6%] female). After adjustment for covariates, no significant differences were found between tenecteplase and alteplase in effectiveness or safety outcomes for the overall cohort, including functional independence at discharge (AOR, 1.00; 95% CI, 0.93-1.07), sICH (AOR, 0.96; 95% CI, 0.83-1.11), and in-hospital mortality or hospice discharge (AOR, 0.98; 95% CI, 0.89-1.07), but significant improvement was found in discharge home (AOR, 1.26; 95% CI, 1.03-1.53), in-hospital mortality (AOR, 0.63; 95% CI, 0.47-0.85), and composite in-hospital mortality or hospice discharge (AOR, 0.78; 95% CI, 0.62-0.97) among those who were eligible for but did not undergo endovascular thrombectomy. Conclusions and Relevance: This large, nationwide comparative effectiveness study using data from routine clinical practice demonstrated similar effectiveness and safety outcomes with tenecteplase compared with alteplase in patients with acute ischemic stroke. This study supports tenecteplase as a reasonable alternative to alteplase.

Validation of a Novel Magnetic Resonance Imaging Biomarker of Infarct Severity to Predict Functional Outcome After Endovascular Thrombectomy

Stroke · 2025-01-30 · 4 citations

BACKGROUND: Endovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the final infarct volume (FIV) on magnetic resonance imaging only accounts for a minority of the treatment effect. An imaging biomarker that more strongly correlates with post-EVT functional outcome would be helpful for clinical prognosis and serve as a surrogate outcome measure in trials of EVT-adjuvant therapies. Here, we aimed to validate a novel magnetic resonance imaging–based metric, infarct density, which leverages post-EVT apparent diffusion coefficient as a marker of infarct severity. METHODS: A retrospective cohort was derived from a single-center prospective EVT registry. Consecutive patients treated with EVT for anterior circulation large vessel occlusion were included from 2018 to 2019 who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b). Magnetic resonance imaging was performed 12 to 48 hours post-EVT and processed via RAPID to quantify FIV using the apparent diffusion coefficient &lt;620 threshold. Lesion volume was also collected using an apparent diffusion coefficient &lt;470 threshold, and infarct density was calculated as: (volume &lt;470/volume &lt;620)×100%. Good outcome was defined as ≤2 on the 90-day modified Rankin Scale. Multivariable logistic regression models quantified the association between clinical/imaging variables and outcome. Receiver operating characteristic analysis quantified model classification performance. RESULTS: Of 319 patients treated with EVT, 272 met inclusion criteria. The mean age was 69±13 years, 41% were female, and 62% achieved a good outcome. After adjusting for clinical and radiographic factors, FIV (adjusted odds ratio, 0.99 per 1 mL [95% CI, 0.98–1.00]; P =0.03) and infarct density (adjusted odds ratio, 0.95 per 1% [95% CI, 0.94–0.97]; P &lt;0.001) were both independently inversely associated with good outcome. The final model incorporating both FIV and infarct density achieved excellent classification performance (area under the curve, 0.87 [95% CI, 0.83–0.91]). Removing infarct density from the model diminished its performance (area under the curve, 0.83 [95% CI, 0.78–0.88]; P =0.01). CONCLUSIONS: Apparent diffusion coefficient–based infarct density after EVT is independently associated with long‐term outcome and provides greater prognostic information than FIV alone. Post-EVT infarct density may be useful in clinical care and as a surrogate outcome measure in trials of EVT-adjuvant therapies.