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Dumot C, Gasimov T, Hatipoglu Majernik G, Gurbuz MS, Erginoglu U, Keles A, Arat A, Baskaya MK. Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes. Neurosurgery 2024:00006123-990000000-01228. [PMID: 38904367 DOI: 10.1227/neu.0000000000003024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 04/16/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes. METHODS This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 pm and 7 am, with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 pm and 7 am, with other times classified as on-hours. RESULTS This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes. CONCLUSION Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Neurosurgery, Hospices Civils de Lyon, Lyon, France
| | - Turab Gasimov
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Mehmet Sabri Gurbuz
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ufuk Erginoglu
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Abdullah Keles
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Anil Arat
- Department of Radiology, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Galecio-Castillo M, Vivanco-Suarez J, Zevallos CB, Dajles A, Weng J, Farooqui M, Ribo M, Jovin TG, Ortega-Gutierrez S. Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e17-e25. [PMID: 35710313 DOI: 10.1136/neurintsurg-2022-018895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Reducing stroke workflow times when performing endovascular thrombectomy is associated with improvement in clinical outcomes. We compared outcomes among large vessel occlusion (LVO) stroke patients following the direct to angiosuite (DTAS) strategy versus standard workflow (SW) when undergoing endovascular therapy. METHODS We conducted a systematic review and meta-analysis to compare rates of functional outcomes, reperfusion, symptomatic intracranial hemorrhage (sICH) and stroke workflow metrics. We included observational studies and clinical trials that compared the DTAS strategy versus SW, and at least one outcome of interest was assessed. Clinical, methodological and statistical heterogeneity were measured, and a random-effects model was used. RESULTS 12 studies were included in the systematic review and 8 in the meta-analysis (n=2890). The DTAS strategy was associated with significant higher odds of good functional outcome at 90 days (47.3% vs 34.9%; OR 1.58, 95% CI 1.16 to 2.14) and a significant average reduction of door-to-puncture (mean differences (MD) -35.09, 95% CI -49.76 to -20.41) and door-to-reperfusion times (MD -32.88, 95% CI -50.75 to -15.01). We found no differences in sICH (OR 0.80, 95% CI 0.53 to 1.20), mortality (OR 1.00, 95% CI 0.60 to 1.67) or successful reperfusion rates (OR 1.37, 95% CI 0.82 to 2.29). Moreover, the DTAS strategy was associated with greater odds of dramatic clinical improvement at 24 hours (OR 1.79, 95% CI 1.15 to 2.79). CONCLUSION Patients undergoing the DTAS strategy had a significant reduction in door-to-puncture and door-to-reperfusion times. This resulted in an increased rate of early neurological and 90-day functional recovery without compromising safety in LVO patients undergoing endovascular thrombectomy.
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Affiliation(s)
| | - Juan Vivanco-Suarez
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andres Dajles
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Julie Weng
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Marc Ribo
- Stroke Unit. Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Lin CW, Huang HY, Guo JH, Chen WL, Shih HM, Chu HT, Wang CC, Hsu TY. Does Weekends Effect Exist in Asia? Analysis of Endovascular Thrombectomy for Acute Ischemic Stroke in A Medical Center. Curr Neurovasc Res 2022; 19:225-231. [PMID: 35894472 PMCID: PMC9900696 DOI: 10.2174/1567202619666220727094020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Discussing the quality measurements based on interrupted time series in ischemic stroke, delays are often attributed to weekends effect. This study compared the metrics and outcomes of emergent endovascular thrombectomy (EST) during working hours versus non-working hours in the emergency department of an Asian medical center. METHODS A total of 297 patients who underwent EST between January 2015 and December 2018 were retrospectively included, with 52.5% of patients presenting during working hours and 47.5% presenting during nights, weekends, or holidays. RESULTS Patients with diabetes were more in non-working hours than in working hours (53.9% vs. 41.0%; p=0.026). It took longer during nonworking hours than working hours in door-to -image times (13 min vs. 12 min; p=0.04) and door-to-groin puncture times (median: 112 min vs. 104 min; p=0.042). Significant statistical differences were not observed between the two groups in neurological outcomes, including successful reperfusion and complications such as intracranial hemorrhage and mortality. However, the change in National Institute of Health Stroke Scale (NIHSS) scores in 24 hours was better in the working-hour group than in the nonworking-hour group (4 vs. 2; p=0.058). CONCLUSION This study revealed that nonworking-hour effects truly exist in patients who received EST. Although delays in door-to-groin puncture times were noticed during nonworking hours, significant differences in neurological functions and mortality were not observed between working and non-working hours. Nevertheless, methods to improve the process during non-working hours should be explored in the future.
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Affiliation(s)
- Chia-Wei Lin
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Hung-Yu Huang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jeng-Hung Guo
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan;,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Wei-Laing Chen
- Department of Neuroradiology, China Medical University Hospital, Taichung, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Department of Public Health, China Medical University, Taipei, Taiwan
| | - Hsueh-Ting Chu
- Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Charles C.N. Wang
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan;,Center for Precision Health Research, Asia University, Taichung, Taiwan,Address correspondence to these authors at the Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan and Center for Precision Health Research, Asia University, Taichung, Taiwan; E-mails: ;
| | - Tai-Yi Hsu
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
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Grandhi R, Ravindra VM, Ney JP, Zaidat O, Taussky P, de Havenon A. Investigating the "Weekend Effect" on Outcomes of Patients Undergoing Endovascular Mechanical Thrombectomy for Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:106013. [PMID: 34375859 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT. METHODS This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes. RESULTS We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS. CONCLUSION These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA.
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA; Department of Neurosurgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr., San Diego, CA 92134, USA.
| | - John P Ney
- Department of Neurology, Boston University, 72 East Concord Street, C-3, MA 02118, USA.
| | - Osama Zaidat
- Department of Neurology, Mercy Health, 2222 Cherry St m200, Toledo, OH 43608, USA.
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84132, USA.
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA.
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Zha M, Yang Q, Liu S, Huang K, Zhang X, Wu M, Cai H, Lv Q, Liu R, Yang D, Liu X. Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry. Stroke Vasc Neurol 2021; 6:640-648. [PMID: 34244447 PMCID: PMC8717780 DOI: 10.1136/svn-2021-000949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry. Methods AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00–7:59 on weekdays) and on-hour (8:00–17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0–2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors. Results Of all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: −21.56; 95% CI −39.96 to −3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group. Conclusions The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.
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Affiliation(s)
- Mingming Zha
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Qingwen Yang
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Shuo Liu
- Department of Internal Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Kangmo Huang
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiaohao Zhang
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Min Wu
- Department of Neurology, Southern Medical University, Guangzhou, Guangdong, China
| | - Haodi Cai
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China
| | - Qiushi Lv
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Rui Liu
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Dong Yang
- Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
| | - Xinfeng Liu
- Department of Neurology, Southeast University, Nanjing, Jiangsu, China .,Department of Neurology, Nanjing Jinling Hospital, Nanjing, Jiangsu, China
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Zha M, Yang Q, Liu S, Wu M, Huang K, Cai H, Zhang X, Lv Q, Liu R, Yang D, Liu X. Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis. Int J Stroke 2021; 17:669-680. [PMID: 33877016 DOI: 10.1177/17474930211012545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). AIM This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. SUMMARY OF REVIEW Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). CONCLUSIONS Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.
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Affiliation(s)
- Mingming Zha
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Qingwen Yang
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Shuo Liu
- Department of Internal Medicine, Medical School of Southeast University, Nanjing, China
| | - Min Wu
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Kangmo Huang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Haodi Cai
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Xiaohao Zhang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Qiushi Lv
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Rui Liu
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Dong Yang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China.,Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China.,Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
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