Improved Workflow’s Effect on Patient Outcomes Following Endovascular Treatment

20s male patient in hospital bed listening to doctor and nurse in hospital
A study was conducted to assess the effect of time to treatment and procedural process on clinical outcomes for patients who received EVT for acute ischemic stroke.

Clinical outcomes of endovascular treatment (EVT) for acute ischemic stroke (AIS) have been improving in the Netherlands, likely resulting from improved workflow timing and higher reperfusion success rates. These findings were published in Stroke.

Data were sourced from the first and second cohorts of the Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. Between 2014 and 2016 (cohort 1; n=1488) and 2016 and 2017 (cohort 2; n=1692), patients who underwent EVT to prevent AIS in the Netherlands were prospectively enrolled in the registry. The primary outcome of this study was modified Rankin Scale (mRS) score through 90 days and secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) up to 48 hours after stroke onset and intracranial hemorrhage. Trends in workflow times and reperfusion success rates over time were evaluated.

The first and second cohorts included 53.4% and 50.8% men; were aged median 71 (IQR, 60-80) and 73 (IQR, 63-81) years (P <.01); their NIHSS scores were 16 (IQR, 11-20) and 16 (IQR, 11-19) points; 22.3% and 25.7% had atrial fibrillation (P =.03); and 15.6% and 12.9% had myocardial infarction (P =.04), respectively.

Cohort 1 was associated with decreased time from onset to first hospital (median, 53 vs 57 min; P =.03) but an increase in time from onset to arterial puncture (median, 208 vs 180 min; P <.01), arrival at interventional hospital to arterial puncture (median, 69 vs 52 min; P <.01), onset to reperfusion (median, 267 vs 233 min; P <.01), and duration of procedure (median, 63 vs 54 min; P <.01).

Patients in cohort 1 were more likely to receive stent retriever and less likely to receive aspiration as first approach technique (P <.01).

Cohort 1 had lower success (57.5% vs 65.7%; P <.01) and success on first attempt (20.9% vs 24.1%; P =.04) rates.

At 90 days, fewer patients in cohort 1 had mRS scores of 2 points or higher (37.9% vs 42.6%; P =.01) and NIHSS scores at 24 to 48 hours were higher (median, 11 vs 9 points; P <.01).

Cohort 2 was associated with improved functional outcomes after adjusting for age, gender, and clinical and imaging characteristics (adjusted common odds ratio [acOR], 1.20; 95% CI, 1.05-1.38), however the difference was attenuated after adjusting for time to reperfusion or reperfusion grade. Similarly, NIHSS scores were lower among the second cohort after adjusting for age, gender, and clinical and imaging characteristics (acOR, -0.95; 95% CI, -1.54 to -0.36) but differences were attenuated after further adjustment.

No cohort differences were observed for 90-day mortality (29.2% vs 29.0%; P =.92), symptomatic intracerebral hemorrhage (5.8% vs 6.0%; P =.83), or symptomatic progression to stroke (9.5% vs 8.7%; P =.48).

This study was limited by not having sufficient data to review the specific workflow changes which resulted in improvements.

“Functional outcomes of EVT-treated patients with acute ischemic stroke have improved over the past 3.5 years,” the study authors noted. “We hope that these results will further inspire everyone involved in acute stroke care to monitor and improve their teams’ performances.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Compagne KCJ, Kappelhof M, Hinsenveld WH, et al. Improvements in endovascular treatment for acute ischemic stroke: A longitudinal study in the MR CLEAN Registry. Stroke. Published online February 9, 2022. doi:10.1161/STROKEAHA.121.034919