In-hospital treatment delays may impact stroke recovery

Delays in in-hospital stroke care (ie, between emergency room (ER) arrival until reperfusion is achieved) may cut years of healthy life in stroke survivors, according to findings from the HERMES* collaboration presented at ISC 2021.

“Delays could occur if brain scanners or angiography suites are occupied … when the stroke patient arrives, or if there are delays in the notification or arrival of the endovascular team to the hospital,” noted study lead author Dr Mohammed Almekhlafi from the University of Calgary, Alberta, Canada, in a press release.

“Our study showed that [in-hospital treatment delays] may have even more severe consequences on stroke recovery than prehospital arrival delays … [As such,] timely successful reperfusion is a critically important determinant of endovascular thrombectomy (EVT) outcome,” added Almekhlafi.

The HERMES collaboration comprised seven trials looking at 781 patients who had EVT following a moderate-to-severe stroke. The team evaluated timeliness of in-hospital stroke care in patients who were treated early** (n=406; mean age 66.2 years, 47 percent female). [ISC 2021, presentation 17]

Median last-known-well(LKW)-to-door time (between symptom onset and ER arrival) was a little over 3 hours, while LKW-to-reperfusion time was about 6 hours.

As onset-to-treatment times are imprecise, door-to-treatment times were evaluated. “These metrics happen in the hospital and are precisely documented,” said Almekhlafi. Door-to-puncture (between ER arrival and arterial puncture) time was just above 1.5 hours, while door-to-reperfusion (DTR) time was slightly over 2 hours.

Patients treated early lost 0.8 years (~10 months) of healthy life for every hour of delay in LKW-to-puncture (LKWTP) time (between ER arrival and start of treatment). More granular time intervals showed a loss of 1.6 months per 10-minute delay and 4.9 days per 1-minute delay.

Compared with late-window patients (ie, LKWTP time of >4 hours) who lost about 0.2 years of healthy life per 1 hour delay in LKWTP time, the effect size among early-treated patients was substantial, noted Almekhlafi.

In terms of door-to-treatment time, every hour of delay in DTR was tied to a loss of 0.92 years (11 months) of healthy life, translating to a loss of almost 2 months per 10-minute delay and 5.6 days per 1-minute delay. The late-window arm saw a loss of 0.86 years of healthy life per 1-hour DTR delay.

Even a second of delay in both LKWTP and DTR times led to a 2-hour loss of healthy life. Collectively, this analysis implies that despite early treatment in stroke patients, post-hospital arrival delays may entail losses in healthy life, stressed Almekhlafi. “Our findings emphasize the importance of continuous monitoring of these time metrics to ensure that speed of care is optimized [to improve door-to-treatment times].”

However, limiting the population to those with favourable imaging studies only may have influenced the findings, he noted. “Future work focusing on time-outcome relationship [should] consider all early-arriving patients irrespective of [imaging studies] to provide further insight into the underlying biology of infarct progression and the importance of timely treatment.”

Also, all patients were taken directly to comprehensive stroke centres that are highly capable of delivering EVT. Ill-equipped facilities may face different setbacks requiring transfer of stroke patients to more equipped treatment facilities.

“[As such,] healthcare systems should strive to optimize workflow and eliminate any barrier preventing timely evaluation and treatment … Fast, urgent delivery of stroke care is crucial for all stroke patients to reduce risk of death and serious disability,” Almekhlafi concluded.

Every second counts

Dr Joseph Broderick from the University of Cincinnati Gardner Neuroscience Institute, Ohio, US, who was unaffiliated with the trial, shared insight on the presentation. “[W]hen you have signs and symptoms of a stroke, every second counts … [I]t can really mean the difference between being … independent or not later in life.”

The ongoing COVID-19 pandemic also disrupted stroke management, noted Broderick. “[T]here’s a sense of anxiety about going to the hospital [during this] time … A lot of [stroke patients were not appropriately treated or] saved … because they got to the hospital too late.”

“[Between] a stroke and COVID-19, there’s no comparison. [The] brain has got to take priority,” underscored Broderick.