A Critical Assessment of the Golden Hour and the Impact of Procedural Timing in Stroke Thrombectomy

BACKGROUND AND PURPOSE: Previous studies in acute ischemic stroke have demonstrated the importance of minimizing delays to endovascular treatment and keeping thrombectomy procedural times at <30–60 minutes. The purpose of this study was to investigate the impact of thrombectomy procedural times on clinical outcomes.

MATERIALS AND METHODS: We retrospectively compared 319 patients having undergone thrombectomy according to procedural time (<30 minutes, 30–60 minutes, and >60 minutes) and time from stroke onset to endovascular therapy (≤6 or >6 hours). Clinical characteristics of patients with postprocedural intracranial hemorrhage were also assessed. Logistic regression was used to determine independent predictors of poor outcome at 90 days (mRS ≥3).

RESULTS: Greater age (OR, 1.03; 95% CI, 1.01–1.06; P = .016), higher admission NIHSS score (OR, 1.10; 95% CI, 1.04–1.16; P = .001), history of diabetes mellitus (OR, 1.96; 95% CI, 1.05–3.65; P = .034), and postprocedural intracranial hemorrhage were independently associated with greater odds of poor outcome. Modified TICI scale scores of 2c (OR, 0.11; 95% CI, 0.04–0.28; P < .001) and 3 (OR, 0.15; 95% CI, 0.06–0.38; P < .001) were associated with reduced odds of poor outcome. Although not statistically significant on univariate analysis, onset to endovascular therapy of >6 hours was independently associated with increased odds of poor outcome (OR, 2.20; 95% CI, 1.11–4.36; P = .024) in the final multivariate model (area under the curve = 0.820). Procedural time was not independently associated with clinical outcome in the final multivariate model (P > .05).

CONCLUSIONS: Thrombectomy procedural times beyond 60 minutes are associated with lower revascularization rates and worse 90-day outcomes. Procedural time itself was not an independent predictor of outcome. While stroke thrombectomy procedures should be performed rapidly, our study emphasizes the significance of achieving revascularization despite the requisite procedural time. However, the potential for revascularization must be weighed against the risks associated with multiple thrombectomy attempts.