Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Hassan Saad; Andrew B Koo; Jonathan A Grossberg; Ma Tianwen; Brian M Howard; Mohammad-Mahdi Sowlat; Bachar El Baba; Ariana Chacon; Pascal Jabbour; Ansaar Rai; Justin Dye; Ali Alaraj; C Michael Cawley; Frank C Tong; Feras Akbik; Aqueel Pabaney; Mohamad Ezzeldin; David Fiorella; Shinichi Yoshimura; Joon-Tae Kim; Nitin Goyal; Adam S Arthur; Isabel Fragata; Fazeel M Siddiqui; Justin Mascitelli; Charles Matouk; Ilko Maier; Min S Park; Michael Levitt; Ramesh Grandhi; Marios-Nikos Psychogios; Stacey Q Wolfe; Robert M Starke; Amir Shaban; Edgar A Samaniego; Omar Tanweer; Daniele G Romano; Pedro Navia; Hugo H Cuellar; Adam J Polifka; Josh Osbun; Mark E Moss; Kaustubh Limaye; Maxim Mokin; Waleed Brinjikji; Ergun Daglioglu; Richard Williamson; David Altschul; Christopher S Ogilvy; Roberto Javier Crosa; Benjamin Gory; Alexandra R Paul; Peter Kan; Walter Casagrande; Shakeel A Chowdhry; Michael F Stiefel; Alejandro M Spiotta; Ali M Alawieh; Stroke Thrombectomy and Aneurysm Registry (STAR)

doi:10.1136/jnis-2025-023906

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Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Journal article

Open access

Peer reviewed

Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment

Hassan Saad, Andrew B Koo, Jonathan A Grossberg, Ma Tianwen, Brian M Howard, Mohammad-Mahdi Sowlat, Bachar El Baba, Ariana Chacon, Pascal Jabbour, Ansaar Rai, …

Journal of neurointerventional surgery, Vol.18(6), pp.1494-1502

06/2026

DOI: 10.1136/jnis-2025-023906

PMID: 40973492

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Abstract

Background Endovascular thrombectomy (EVT) has transformed acute ischemic stroke (AIS) care, with onset-to-puncture (OTP) time widely recognized as a critical determinant of outcome. However, emerging evidence suggests that in-hospital procedure time (PT)—from arterial puncture to final recanalization—may have an equally or more significant impact. This study examines the relative contribution of PT versus OTP to functional outcomes in patients with AIS undergoing EVT. Methods A retrospective analysis was conducted of 6644 patients with AIS treated at 44 international stroke centers from the Stroke Thrombectomy and Aneurysm Registry (STAR; 2016–2023). Multivariable regression, time-equivalence analysis, and marginal effects modeling were used to assess associations between PT, OTP, and 90-day modified Rankin Scale (mRS) outcomes. Centers were stratified by procedural efficiency and compared using propensity score matching (PSM). Mediation analysis evaluated whether PT accounted for inter-center differences. Results PT and OTP were independently associated with functional outcomes; however, PT had a significantly stronger effect (adjusted OR for mRS 0–2: PT=0.56 vs OTP=0.96 per hour). Each 5 min increase in PT was equivalent to 78–100 min of additional OTP in outcome impact. Centers with faster average PT had higher rates of functional independence (number needed to treat (NNT)=10), fewer complications, and lower symptomatic intracranial hemorrhage rates. PT significantly mediated the relationship between center tier and outcomes (Sobel’s P<0.001). Conclusion While minimizing OTP remains important, PT exerts a greater influence on outcomes after EVT. Procedural efficiency should be emphasized in stroke systems of care and included in center performance metrics to improve patient outcomes.

Angiography

Blood Flow

Brain

Stroke

Ischemic stroke

Reperfusion

Details

Title: Subtitle: Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment
Creators: Hassan Saad - Emory University
Andrew B Koo - Yale University
Jonathan A Grossberg - Emory University
Ma Tianwen - Emory University
Brian M Howard - Emory University
Mohammad-Mahdi Sowlat - Medical University of South Carolina
Bachar El Baba - Emory University
Ariana Chacon - Emory University
Pascal Jabbour - Thomas Jefferson University
Ansaar Rai - West Virginia University
Justin Dye - Loma Linda University
Ali Alaraj - University of Illinois Chicago
C Michael Cawley - Emory University
Frank C Tong - Emory University
Feras Akbik - Emory University
Aqueel Pabaney - Emory University
Mohamad Ezzeldin - Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA
David Fiorella - Stony Brook University
Shinichi Yoshimura - Hyogo Medical University
Joon-Tae Kim - Chonnam National University Hospital
Nitin Goyal - Semmes Murphey Foundation
Adam S Arthur - University of Tennessee Health Science Center
Isabel Fragata - Unidade Local de Saúde de São José
Fazeel M Siddiqui - Metro Health Hospital
Justin Mascitelli - The University of Texas at San Antonio Health Science Center
Charles Matouk - Yale University
Ilko Maier - Universitätsmedizin Göttingen
Min S Park - University of Utah
Michael Levitt - University of Washington
Ramesh Grandhi - University of Utah
Marios-Nikos Psychogios - University Hospital of Basel
Stacey Q Wolfe - Wake Forest University
Robert M Starke - University of Miami
Amir Shaban - University of Iowa
Edgar A Samaniego - University of Iowa
Omar Tanweer - NYU Langone Health
Daniele G Romano - Ospedali Riuniti San Giovanni di Dio e Ruggi d'Aragona
Pedro Navia - Hospital Universitario La Paz
Hugo H Cuellar - Louisiana State University Health Sciences Center Shreveport
Adam J Polifka - University of Florida
Josh Osbun - Washington University in St. Louis School of Medicine
Mark E Moss - Washington Regional Medical Center
Kaustubh Limaye - Indiana University Bloomington
Maxim Mokin - University of South Florida
Waleed Brinjikji - Mayo Clinic
Ergun Daglioglu - Ankara Bilkent City Hospital
Richard Williamson - Allegheny Health Network
David Altschul - Montefiore Medical Center
Christopher S Ogilvy - Beth Israel Deaconess Hospital
Roberto Javier Crosa - Universidad de Montevideo
Benjamin Gory - Centre Hospitalier Régional et Universitaire de Nancy
Alexandra R Paul - Albany Medical Center Hospital
Peter Kan - The University of Texas Medical Branch at Galveston
Walter Casagrande - Hospital Fernández
Shakeel A Chowdhry - Endeavor Health
Michael F Stiefel - Piedmont HealthCare
Alejandro M Spiotta - Medical University of South Carolina
Ali M Alawieh - Emory University
Stroke Thrombectomy and Aneurysm Registry (STAR)
Resource Type: Journal article
Publication Details: Journal of neurointerventional surgery, Vol.18(6), pp.1494-1502
DOI: 10.1136/jnis-2025-023906
PMID: 40973492
NLM abbreviation: J Neurointerv Surg
ISSN: 1759-8478
eISSN: 1759-8486
Publisher: BMJ Publishing Group Ltd
Language: English
Electronic publication date: 09/19/2025
Date published: 06/2026
Academic Unit: Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
Record Identifier: 9984964239202771

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