A Decade of Improvement in Door‐to‐Puncture Times for Mechanical Thrombectomy But Ongoing Stagnation in Prehospital Care

Background Systems of care surrounding endovascular therapy for stroke have garnered much attention in recent years. In‐hospital metrics, such as “door‐to‐puncture” and procedure times have been areas for quality improvement. The temporal trend and clinical significance of prehospital “onset‐to‐door” time, however, remains unknown. Methods We performed a systematic review of time metric data from all published randomized controlled and investigational device exemption trials involving endovascular therapy for stroke between 2005 and 2019 (n=26). Second, we conducted a record‐level observational analysis on a total of 3512 patients from 3 real‐world registries (Mechanical Embolus Removal in Cerebral Ischemia [MERCI], Thrombectomy REvascularization of Large Vessel Occlusions in Acute Ischemic Stroke [TREVO], and TREVO Stent‐Retriever Acute Stroke [TRACK]), together with 4 prospective trials (MERCI trial, Multi‐MERCI, TREVO‐EU, and TREVO‐2). Only patients receiving mechanical thrombectomy within 9 hours from onset‐to‐puncture time were included. Predictors of good outcome were identified using generalized linear mixed modeling. Results Door‐to‐puncture times (slope=−5.83 min/y; R2=0.25; P=0.046), procedure times (slope=−3.78 min/y; R2=0.54; P