“Time is brain”: Functional outcomes in large vessel occlusion stroke


Prof. V Nagarajan, Chairman & Head Neurosciences Research & Translational Task Force, ICMR, New Delhi; Chairman, IEC, Govt. Madurai Medical College; Director, VN Neuro Care Centre, Madurai    06 January 2023

 Functional recovery is excellent in stroke patients due to large vessel occlusions who had been administered intravenous thrombolysis (IVT) before being shifted to a higher stroke center, suggests a recent study published in the journal Neurology.1 The chances of complications and mortality were also lower.


An international research team sought to investigate if IVT administered before shifting the patient from a primary stroke center to a comprehensive stroke center would benefit patients with large vessel occlusions. For this they conducted a systematic review and meta-analysis of 6 observational studies involving 1723 patients. The mean age of the selected participants was 71 years; women comprised a little over half (51%) of the enrolled patients. Fifty-three percent of patients had received IVT at the primary stroke center. Occurrence of symptomatic intracranial hemorrhage (sICH) within 48 hours and death due to any cause were the measures for safety outcomes.


No between-group difference was observed for the mean onset-to-groin puncture time (mean difference -20 min). Disability at 3 months was reduced in patients who received IVT prior to transfer with odds ratio (OR 1.98). The chances of excellent (modified Rankin Scale score 0-1) or good (modified Rankin Scale score 0-2) functional outcome at 3 months were higher among patients who received IVT prior to transfer with odds ratio (OR) of 1.70 and 1.62 respectively with no increased risk of sICH (OR 0.87) or mortality (OR 0.55). After adjustment, patients receiving IVT at a PSC still had greater odds of excellent functional outcome with adjusted OR (aOR) of 1.32 and lower chances of mortality (aOR 0.50).


“Time is brain” in patients with acute stroke.


IVT followed by mechanical thrombectomy is the standard of care for patients with acute ischemic stroke caused by large vessel occlusion. However, time plays a crucial role in the effectiveness of this approach. Mechanical thrombectomy is usually carried out at an advanced stroke center termed as the “mothership”. However, not all patients are directly brought to the CSC for mechanical thrombectomy. Some patients are admitted to the nearest stroke center, which is equipped for IVT, termed the “drip and ship” pathway.2 Some patients who receive IVT may still require transfer to a CSC for mechanical thrombectomy, which may delay the onset-to-reperfusion time. In the present study, the onset-to-groin puncture time was not significantly different between the two groups of patients. But those who had received IVT prior to being transferred to a CSC had good functional outcomes and lesser odds of mortality.3




  1. Katsanos AH, et al. Intravenous thrombolysis initiated before transfer for endovascular stroke thrombectomy: a systematic review and meta-analysis. Neurology. 2022 Dec 29:10.1212/WNL.0000000000206784
  2. Ismail M, et al. Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis. J Neurointerv Surg. 2019;11:14–9. doi: 10.1136/neurintsurg-2018-014249.
  3. Nicholls JK, et al. Emerging detection techniques for large vessel occlusion stroke: a scoping review. Front Neurol. 2022 Jan 6;12:780324. doi: 10.3389/fneur.2021.780324.

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