A Decade of Improvement in Door-to-Puncture Times for Mechanical Thrombectomy But Ongoing Stagnation in Prehospital Care.

Background: Systems of care surrounding endovascular therapy for stroke have garnered much attention in recent years. In-hospital metrics, such as "door-to-puncture" and procedure times have been areas for quality improvement. The temporal trend and clinical significance of prehospital "onset-to-door" time, however, remains unknown. Methods: We performed a systematic review of time metric data from all published randomized controlled and investigational device exemption trials involving endovascular therapy for stroke between 2005 and 2019 (n=26). Second, we conducted a record-level observational analysis on a total of 3512 patients from 3 real-world registries (Mechanical Embolus Removal in Cerebral Ischemia [MERCI], Thrombectomy REvascularization of Large Vessel Occlusions in Acute Ischemic Stroke [TREVO], and TREVO Stent-Retriever Acute Stroke [TRACK]), together with 4 prospective trials (MERCI trial, Multi-MERCI, TREVO-EU, and TREVO-2). Only patients receiving mechanical thrombectomy within 9 hours from onset-to-puncture time were included. Predictors of good outcome were identified using generalized linear mixed modeling. Results: Door-to-puncture times (slope=-5.83 min/y; R2=0.25; P=0.046), procedure times (slope=-3.78 min/y; R2=0.54; P<0.001), and onset-to-reperfusion times (slope=-11.82 min/y; R2=0.57; P<0.001) improved over the years among previously published randomized controlled trials/investigational device exemption trials from 2005 to 2019. The prehospital metric of onset-to-door time, however, remained statistically unchanged (slope=1.03 min/y; R2<0.01; P=0.806). Pooled analysis from record-level data demonstrated a similar temporal trend where door-to-puncture, procedure, and onset-to-reperfusion times declined by an average of 12 minutes (R2=0.45; P<0.0001), 6 minutes (R2=0.27; P<0.0001), and 8 minutes per year (R2=0.18; P<0.0001), respectively, over a similar time period. Time from onset to door, however, did not improve (3.6 min/y; R2=0.34; P=0.005). In a backward-selection regression model, onset-to-door time was found to be a significant predictor of patient outcomes, where every hour delay in hospital arrival correlated with a 14% reduction in the odds of a good outcome. Conclusions: "Door-to-puncture" and procedure times have seen significant improvements over the past decade. The prehospital component of "onset-to-door" time, however, has remained stagnant. This presents an unrealized opportunity to enhance patient outcomes through improved systems of care in the prehospital setting.