{
  "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.",
  "authors": [
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Hassan Saad"
    },
    {
      "affiliations": [
        "Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA"
      ],
      "name": "Andrew B Koo"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Jonathan A Grossberg"
    },
    {
      "affiliations": [
        "Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA"
      ],
      "name": "Ma Tianwen"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Brian M Howard"
    },
    {
      "affiliations": [
        "Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA"
      ],
      "name": "Mohammad-Mahdi Sowlat"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Bachar El Baba"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Ariana Chacon"
    },
    {
      "affiliations": [
        "Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA"
      ],
      "name": "Pascal Jabbour"
    },
    {
      "affiliations": [
        "Neurosurgery, West Virginia University, Morgantown, West Virginia, USA"
      ],
      "name": "Ansaar Rai"
    },
    {
      "affiliations": [
        "Neurosurgery, Loma Linda University Health, Loma Linda, California, USA"
      ],
      "name": "Justin Dye"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA"
      ],
      "name": "Ali Alaraj"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "C Michael Cawley"
    },
    {
      "affiliations": [
        "Radiology, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Frank C Tong"
    },
    {
      "affiliations": [
        "Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA"
      ],
      "name": "Feras Akbik"
    },
    {
      "affiliations": [
        "Emory University, Atlanta, Georgia, USA"
      ],
      "name": "Aqueel Pabaney"
    },
    {
      "affiliations": [
        "Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA"
      ],
      "name": "Mohamad Ezzeldin"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA"
      ],
      "name": "David Fiorella"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan"
      ],
      "name": "Shinichi Yoshimura"
    },
    {
      "affiliations": [
        "Department of Neurology, Chonnam National University Hospital, Dong-gu, Korea (the Republic of)"
      ],
      "name": "Joon-Tae Kim"
    },
    {
      "affiliations": [
        "Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA"
      ],
      "name": "Nitin Goyal"
    },
    {
      "affiliations": [
        "Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA",
        "Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA"
      ],
      "name": "Adam S Arthur"
    },
    {
      "affiliations": [
        "Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal"
      ],
      "name": "Isabel Fragata"
    },
    {
      "affiliations": [
        "Neuroscience, Metro Health Hospital, Wyoming, Michigan, USA"
      ],
      "name": "Fazeel M Siddiqui"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA"
      ],
      "name": "Justin Mascitelli"
    },
    {
      "affiliations": [
        "Neurosurgery, Yale University, New Haven, Connecticut, USA"
      ],
      "name": "Charles Matouk"
    },
    {
      "affiliations": [
        "Neurology, Universitätsmedizin Göttingen, Göttingen, Germany"
      ],
      "name": "Ilko Maier"
    },
    {
      "affiliations": [
        "Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA"
      ],
      "name": "Min S Park"
    },
    {
      "affiliations": [
        "Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA"
      ],
      "name": "Michael Levitt"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA"
      ],
      "name": "Ramesh Grandhi"
    },
    {
      "affiliations": [
        "Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland"
      ],
      "name": "Marios-Nikos Psychogios"
    },
    {
      "affiliations": [
        "Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA"
      ],
      "name": "Stacey Q Wolfe"
    },
    {
      "affiliations": [
        "Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA",
        "University of Miami School of Medicine, Miami, Florida, USA"
      ],
      "name": "Robert M Starke"
    },
    {
      "affiliations": [
        "Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA"
      ],
      "name": "Amir Shaban"
    },
    {
      "affiliations": [
        "Neurology, University of Iowa Health Care, Iowa City, Iowa, USA"
      ],
      "name": "Edgar A Samaniego"
    },
    {
      "affiliations": [
        "NYU Langone Health, New York, New York, USA"
      ],
      "name": "Omar Tanweer"
    },
    {
      "affiliations": [
        "Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona’, Salerno, Italy"
      ],
      "name": "Daniele G Romano"
    },
    {
      "affiliations": [
        "Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain"
      ],
      "name": "Pedro Navia"
    },
    {
      "affiliations": [
        "Department of Radiology and Interventional Radiology, LSU Health Shreveport, Shreveport, Louisiana, USA"
      ],
      "name": "Hugo H Cuellar"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, University of Florida, Gainesville, Florida, USA"
      ],
      "name": "Adam J Polifka"
    },
    {
      "affiliations": [
        "Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA"
      ],
      "name": "Josh Osbun"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA"
      ],
      "name": "Mark E Moss"
    },
    {
      "affiliations": [
        "Department of Neurology, Indiana University, Bloomington, Indiana, USA"
      ],
      "name": "Kaustubh Limaye"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, University of South Florida, Tampa, Florida, USA"
      ],
      "name": "Maxim Mokin"
    },
    {
      "affiliations": [
        "Mayo Clinic Minnesota, Rochester, Minnesota, USA"
      ],
      "name": "Waleed Brinjikji"
    },
    {
      "affiliations": [
        "Neurosurgery, Ministry of Health Ankara Bilkent City Hospital, Çankaya, Turkey"
      ],
      "name": "Ergun Daglioglu"
    },
    {
      "affiliations": [
        "Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA"
      ],
      "name": "Richard Williamson"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Montefiore Medical Center, New York, New York, USA"
      ],
      "name": "David Altschul"
    },
    {
      "affiliations": [
        "Neurosurgery, BIDMC, Boston, Massachusetts, USA"
      ],
      "name": "Christopher S Ogilvy"
    },
    {
      "affiliations": [
        "Endovascular Neurosurgery, Medica Uruguaya, Montevideo, Montevideo, Uruguay"
      ],
      "name": "Roberto Javier Crosa"
    },
    {
      "affiliations": [
        "Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France"
      ],
      "name": "Benjamin Gory"
    },
    {
      "affiliations": [
        "Department of Neurosurgery, Albany Medical Center, Albany, New York, USA"
      ],
      "name": "Alexandra R Paul"
    },
    {
      "affiliations": [
        "Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA"
      ],
      "name": "Peter Kan"
    },
    {
      "affiliations": [
        "Neurosurgery, Hospital Juan A. Fernandez, Buenos Aires, Argentina"
      ],
      "name": "Walter Casagrande"
    },
    {
      "affiliations": [
        "Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA"
      ],
      "name": "Shakeel A Chowdhry"
    },
    {
      "affiliations": [
        "Vascular Neurosurgery, Piedmont Healthcare Inc, Atlanta, Georgia, USA"
      ],
      "name": "Michael F Stiefel"
    },
    {
      "affiliations": [
        "Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA"
      ],
      "name": "Alejandro M Spiotta"
    },
    {
      "affiliations": [
        "Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA",
        "Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA"
      ],
      "name": "Ali M Alawieh"
    },
    {
      "affiliations": [],
      "name": "on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR)"
    }
  ],
  "title": "Procedure duration predicts outcomes more than prehospital delay in endovascular stroke treatment",
  "uid": "c36d076a-55fb-5950-ad6f-d44a10705906"
}