Door-In-Door-Out Time Effect on Clinical Outcome According to Reperfusion Time in Endovascular Treatment

Door-in-door-out time (DIDO) in nonthrombectomy stroke centers is a key performance indicator in acute stroke care. Nonetheless, the relative importance of DIDO on outcome in patients transferred for endovascular treatment (EVT) is not widely known. Therefore, we aim to explore the association between DIDO and clinical outcome according to onset to reperfusion time in patients undergoing EVT.

Observational multicenter study including patients transferred to a thrombectomy-capable center from a local stroke center who underwent thrombectomy. The primary outcome was favorable clinical outcome, as evaluated by a modified Rankin Scale score of 0 to 2 at 3 months. We evaluated the association between DIDO and clinical outcome according to onset to reperfusion time and factors related to shorter DIDO time.

Among 2710 patients transferred for thrombectomy evaluation, 970 (43.8%) patients received EVT. Median baseline National Institutes of Health Stroke Scale and DIDO time were 12 (interquartile range [IQR], 6-19) and 83 minutes (IQR, 66-108), respectively. Among patients undergoing EVT, no association was found between DIDO and clinical outcome. Considering only patients treated in the early time window (onset to reperfusion time ≤240 minutes), patients with favorable outcome had a shorter DIDO (60 [IQR, 52-68] versus 73 [IQR, 61-83] minutes; P=0.013). A receiver operating characteristic curve identified a cutoff of 67 minutes of DIDO time that better predicted favorable outcome (sensitivity, 70%; specificity, 73%; area under the curve, 0.741). A multivariate analysis showed that DIDO ≤67 minutes emerged as an independent factor associated with favorable outcome (odds ratio [OR], 5.29 [95% CI, 1.38-20.27]; P=0.015). Door to computed tomography time was the only factor associated with DIDO ≤67 minutes (OR, 1.113 [95% CI, 1.018-1.261]; P=0.022) in a multivariate analysis in this time frame.

In transferred patients undergoing EVT, DIDO has a significant impact on clinical outcome, mainly in the first hours from stroke onset. A benchmark of 67 minutes in DIDO time is proposed. Shorter door to computed tomography time appears to be an independent factor associated to achieve DIDO time ≤67 minutes. Measures to optimize workflow into referral centers are warranted.