Differential Impact of Onset-to-puncture and Procedural Time on Outcomes in Acute Ischemic Stroke: A Multicenter Study

Introduction: Stroke systems of care have evolved, with a focus on minimizing time to recanalization in acute ischemic stroke (AIS). While onset-to-puncture time (OTP) is emphasized for thrombectomy-capable centers (TSCs), emerging data suggest that procedural time (PT)—the time from arterial puncture to recanalization—may more strongly predict outcomes. This study investigates the differential impact of OTP versus PT on functional outcomes in AIS.

Methods: We conducted a multicenter cohort study from the Stroke Thrombectomy and Aneurysm Registry (STAR), including 6,644 AIS patients treated with mechanical thrombectomy from 44 international centers (2016–2023). Data on demographics, comorbidities, OTP, PT, and 90-day outcomes were analyzed. Logistic regression and marginal effects models evaluated OTP and PT as predictors of 90-day functional independence (modified Rankin Scale [mRS] 0–2) and mortality.

Results: Mean OTP was 440±414 minutes; mean PT was 56±58 minutes. Logistic regression showed both OTP (aOR 0.96; 95% CI 0.95–0.97) and PT (aOR 0.56; 95% CI 0.50–0.63) independently predicted mRS 0–2 at 90 days, with PT demonstrating a stronger effect. Marginal effect analysis revealed that every 5-minute increase in PT equated to an 81-minute OTP increase in predicting functional independence. Patients at high-efficiency centers (shorter PT) had significantly better outcomes, with an absolute risk reduction in poor outcomes of 8% (NNT = 8).

Conclusion : Procedural time is a critical determinant of AIS outcomes, with a greater impact than OTP. Redirecting patients to centers with high procedural efficiency may yield better functional outcomes, underscoring the need to prioritize PT alongside traditional OTP metrics in stroke triage protocols.