Minor stroke, major stakes: impact of procedure duration on thrombectomy outcomes in minor stroke.
Publication/Presentation Date
10-1-2026
Abstract
OBJECTIVE: Endovascular thrombectomy (EVT) for acute large-vessel occlusion stroke is well established, yet its role in patients presenting with minor stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score < 6) remains unclear. Prior studies have not accounted for intraprocedural factors that may influence outcomes in this subgroup.
METHODS: The authors analyzed 5693 patients from the STAR (Stroke and Thrombectomy and Aneurysm Registry), including 398 with low NIHSS scores, to evaluate the association between procedure time (PT) and outcomes. Among patients with low NIHSS scores, propensity score matching was used to compare outcomes between those with PT ≤ 35 versus > 35 minutes, a cutoff defined using receiver operating characteristic curve analysis. The authors performed a meta-analysis of studies reporting best medical management (BMM) outcomes in patients with low NIHSS scores. To compare these with EVT-treated patients, a matched BMM comparator cohort using stratification on pooled baseline characteristics was constructed. Outcomes included 90-day functional independence (modified Rankin Scale [mRS] scores 0-2), intracranial hemorrhage, and mortality.
RESULTS: PT had a stronger negative effect on outcomes in patients with low NIHSS scores compared with those with high scores, with a steeper decline in functional independence per minute of PT (slope: -0.45% vs -0.21%; p = 0.03 for interaction). Among patients with low scores, PT ≤ 35 minutes was associated with higher 90-day functional independence compared with the propensity score-matching cohort with PT > 35 minutes (82.6% vs 59.0%, p < 0.001). When benchmarked against BMM (75.2% mRS scores 0-2), patients undergoing EVT within 35 minutes had superior outcomes (85.1%, p = 0.047). In contrast, EVT with PT > 35 minutes resulted in worse outcomes than BMM (mRS scores 0-2: 59.8%, p = 0.008). The number needed to treat for PT ≤ 35 minutes was 10, whereas PT > 35 minutes yielded a number needed to harm of 6.
CONCLUSIONS: PT critically modulates the benefit of EVT in minor stroke. While efficient EVT yields better outcomes than BMM, prolonged procedures are associated with harm. These findings may explain prior inconsistent evidence on EVT in patients with low NIHSS scores and underscore the need to individualize procedural thresholds in this population.
Volume
145
Issue
4
First Page
979
Last Page
990
ISSN
1933-0693
Published In/Presented At
Abo Kasem, R., El Baba, B., Ma, T., Zelmanovich, R., Pabaney, A., Raheb Khelo, R., Giraudo, F., Chacon, A., Chandler, K., Elawady, S. S., Chalhoub, R., Howard, B. M., Levitt, M. R., Grandhi, R., Mascitelli, J., Cawley, C. M., Akbik, F., Chisango, Z., Quintero Wolfe, S., Kim, J. T., … Alawieh, A. M. (2026). Minor stroke, major stakes: impact of procedure duration on thrombectomy outcomes in minor stroke. Journal of neurosurgery, 145(4), 979–990. https://doi.org/10.3171/2026.2.JNS252558
Disciplines
Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods
PubMedID
42468039
Department(s)
Administration and Leadership
Document Type
Article