Reducing Door-to-Puncture Time with a Streamlined MRI-First Workflow for Endovascular Thrombectomy

Achieving door-to-puncture (D2P) times of less than 60 minutes remains challenging in endovascular thrombectomy (EVT), particularly within MRI-based triage systems. We evaluated whether implementation of an optimized workflow within an MRI-first triage strategy was associated with reduced D2P times.

We conducted a retrospective, single-center, before-and-after observational study of consecutive patients who underwent EVT for acute ischemic stroke between September 2023 and August 2025. The optimized workflow, implemented on February 1, 2025, incorporated prehospital emergent large-vessel occlusion screening, early EVT team activation, advance preparation of MRI and angiography suites, omission of routine non-contrast CT, and parallel processing of patient evaluation and informed consent. The primary outcome was D2P time. Secondary outcomes included puncture-to-reperfusion (P2R) time, onset-to-reperfusion (O2R) time, 90-day functional outcomes, successful reperfusion, and symptomatic intracranial hemorrhage (sICH).

A total of 177 patients were included: 124 in the previous-workflow group and 53 in the post-implementation group. Median D2P time decreased significantly from 76 minutes (interquartile range [IQR], 63-89) to 55 minutes (IQR, 45.5-75; p <0.001). P2R time was significantly longer in the post-implementation group (54 vs. 67 minutes; p = 0.047), whereas O2R time, successful reperfusion rates (Thrombolysis in Cerebral Infarction 2b-3), and sICH rates did not differ significantly between groups. The proportion of patients with good functional outcomes (modified Rankin Scale [mRS] score 0-2) was 30.7% in the previous-workflow group and 43.4% in the post-implementation group (p = 0.102). The proportion of patients with excellent outcomes (mRS score 0-1) was 16.9% and 32.1%, respectively (p = 0.029). Among the post-implementation cohort, 23 of 53 patients (43.4%) were managed under the optimized workflow; their median D2P time was 45 minutes.

Implementation of an optimized workflow within an MRI-first imaging strategy was associated with a substantial reduction in D2P time without an apparent increase in procedural complications. Although clinical outcomes appeared to improve, these findings should be interpreted cautiously given baseline imbalances and the observational study design. These results support the feasibility of achieving sub-60-minute D2P times within MRI-first triage systems through structured workflow redesign.