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Original research
Comprehensive analysis of the impact of procedure time and the ‘golden hour’ in subpopulations of stroke thrombectomy patients
  1. Makenna Ash1,
  2. Laurie Dimisko2,
  3. Reda M Chalhoub3,
  4. Brian M Howard1,4,
  5. C Michael Cawley1,
  6. Charles Matouk5,
  7. Aqueel Pabaney6,
  8. Alejandro M Spiotta3,
  9. Pascal Jabbour7,
  10. Ilko Maier8,
  11. Stacey Q Wolfe9,
  12. Ansaar T Rai10,
  13. Joon-tae Kim11,
  14. Marios-Nikos Psychogios12,
  15. Justin R Mascitelli13,
  16. Robert M Starke14,15,
  17. Amir Shaban16,
  18. Shinichi Yoshimura17,
  19. Reade De Leacy18,
  20. Peter Kan19,
  21. Isabel Fragata20,
  22. Adam J Polifka21,
  23. Adam S Arthur22,23,
  24. Min S Park24,
  25. Roberto Javier Crosa25,
  26. Richard Williamson26,
  27. Travis M Dumont27,
  28. Michael R Levitt28,
  29. Sami Al Kasab29,
  30. Stavropoula I Tjoumakaris7,
  31. Jan Liman8,
  32. Hassan Saad1,
  33. Edgar A Samaniego30,
  34. Kyle M Fargen31,
  35. Jonathan A Grossberg32,
  36. Ali Alawieh1
  37. on Behalf of STAR collaborators
  1. 1Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
  3. 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  5. 5Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  6. 6Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
  7. 7Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  8. 8Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
  9. 9Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  10. 10Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
  11. 11Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
  12. 12Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  13. 13Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  14. 14Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  15. 15University of Miami School of Medicine, Miami, Florida, USA
  16. 16Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
  17. 17Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  18. 18Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  19. 19Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  20. 20Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  21. 21Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  22. 22Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  23. 23Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  24. 24Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  25. 25Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  26. 26Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
  27. 27Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  28. 28Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  29. 29Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  30. 30Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  31. 31Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
  32. 32Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  1. Correspondence to Dr Ali Alawieh, Department of Neurosurgery, Emory University, Atlanta, GA 30307, USA; ali.mostafa.alawieh{at}; Dr Jonathan A Grossberg, Department of Neurosurgery, Emory University, Atlanta, GA 30307, USA; jonathan.a.grossberg{at}


Objective To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.

Methods This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0–2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation.

Results Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3–6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the ‘golden hour’, poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time.

Conclusions In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.

  • stroke
  • thrombectomy

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @ChalhoubReda, @BrianHoward_MD, @PascalJabbourMD, @Ansaar_Rai, @jmascite, @Starke_neurosurgery, @ashabanmd, @rdeleacymd, @PeterKa80460001, @AdamArthurMD, @rocrossa, @DrMichaelLevitt, @stavtjouamakris, @JAGrossbergMD

  • Contributors AA, JAG, and AMS conceived the study. AA and AMS are the guarantors of the study. AA and MA performed the analyses. AA, JAG, and MA wrote the first draft of manuscript. All remaining authors contributed data, discussed the results, and contributed to editing and revising the final version of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CMC: Consultant-Silk Road, Penumbra, Microvention, Cerevasc, Stryker, Speaker-Silk Road, Penumbra; AMS: Consultant- Stryker, Penumbra, Terumo, RapidAI; PJ: Consultant-Balt, Cerus, Microvention, Medtronic; M-NP: Honoraria - Stryker, Medtronic, Penumbra, Acandis, Phenox, Siemens Healthineers, Research Support-Swiss National Science Foundation, Bangerter-Rhyner Stiftung, Stryker, Phenox, Medtronic, Rapid, Penumbra, Siemens Healthineer; RDL: Research funding: Hyprevention, Kaneka Medical, Siemens Healthineers, SNIS foundation; Consultant: Stryker Neurovascular, imperative care, Cerenovus, Asahi Intec; Stock: synchron, endostream, Q’Apel, spartan micro; PK: Consultant: Stryker, Microvention, Imperative Care; AJP: Consultant: Stryker, Depuy Synthes; ASA: Research grants: Balt, Medtronic, Microvention, Penumbra and Siemens; Consultant: Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker; Shareholder: Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI; MRL: Research grants: Stryker, Medtronic; Consultant: Medtronic, Aeaean Advisers; Shareholder: Hyperion Surgical, Proprio, Synchron, Cerebrotech, Fluid Biomed, Stereotaxis; SIT: Consultant: Microvention, Medtronic; JAG: Grant support- Georgia Research Alliance, Department of Defense, Emory Medical Care Foundation, Neurosurgery Catalyst, Stock- NTI, Cognition, AA: Research grants: NIH, AHA, Department of VA.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.