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Original research
The impact of evidence: evolving therapy for acute ischemic stroke in a large healthcare system
  1. Justin R Mascitelli1,
  2. Natalie Wilson2,
  3. Hazem Shoirah2,
  4. Reade A De Leacy1,
  5. Sunil V Furtado1,
  6. Srinivasan Paramasivam1,
  7. Eric K Oermann1,
  8. William J Mack3,
  9. Stanley Tuhrim2,
  10. Neha S Dangayach1,
  11. Stephan A Meyer1,
  12. Joshua B Bederson1,
  13. J Mocco1,
  14. Johanna T Fifi1
  1. 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  3. 3Department of Neurosurgery, Keck Medicine of USC, Los Angeles, California, USA
  1. Correspondence to Dr Johanna T Fifi, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Klingenstein Clinical Center, 1-North, 1450 Madison Avenue, New York, NY 10029, USA; Johanna.Fifi{at}


Background With a recent surge of clinical trials, the treatment of ischemic stroke has undergone dramatic changes.

Objective To evaluate the impact of evidence and a revamped stroke protocol on a large healthcare system.

Methods A retrospective review of 69 patients with ischemic stroke treated with intra-arterial therapy was carried out. Cohort 1 included patients treated before implementation of a new stroke protocol, and cohort 2 after implementation. Angiographic outcome was graded using the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS).

Results Primary outcomes comparing cohorts demonstrated decreased arrival-to-puncture time (cohort 2: 104 vs cohort 1: 181 min, p<0.001), similar TICI 2b/3 rates (86.5% vs 81.3%, p=0.5530), and similar percentage of patients with discharge mRS 0–2 (18.9% vs 21.9%, p=0.7740). Notable secondary outcomes for cohort 2 included decreased puncture-to-first pass time (34 vs 53 min, p <0.001), increased TICI 3 rates (37.8% vs 18.8%, p=0.0290), a trend toward greater improvements in NIHSS on postoperative day 1 (6.8 vs 2.6, p=0.0980) and discharge (9.5 vs 6.7, p=0.1130), and a trend toward increased percentage of patients discharged with mRS 0–3 (48.6% vs 34.4%, p=0.3280 NS). There were similar rates of symptomatic intracerebral hemorrhage (10.8% vs 9.4%, p=0.9570) and death (10.8% vs 15.6%, p=0.5530).

Conclusions An interdisciplinary and rapid response to the emergence of strong clinical evidence can result in dramatic changes in a large healthcare system.

  • Stroke
  • Thrombectomy

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  • Contributors All authors participated in manuscript editing and preparation. JRM, NW, HS, RADL, and SVF performed the data collection. WJM performed the angiographic review. EKO performed the statistical analysis. JRM and JTF supervised the study.

  • Competing interests SP is a consultant to Microvention. WJM is consultant to Penumbra and Lazarus Effect. JM has the following conflicts of interest: National/international principal investigator (PI)/Co-PI for the following trials: THERAPY (PI), FEAT (PI), AMERICA (PI), LARGE (Co-PI), POSITIVE (Co-PI). He is on the steering committee for the MAPS trial. Consultant: Lazarus Effect, Reverse, Pulsar, Edge Therapeutics, Reverse, Medina. Investor: Blockade Medical, Medina, Lazarus Effect. JF is a consultant to Microvention and Penumbra and is an investor in Lazarus Effect. SAM is a consultant to Medtronic and Stryker.

  • Ethics approval Insitutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.