Endovascular Treatment For Ischemic Stroke Research Articles

Endovascular Treatment of Ischemic Stroke due to Acute Carotid Dissection: A Report and Review of the Literature

Endovascular Treatment of Ischemic Stroke due to Acute Carotid Dissection: A Report and Review of the Literature

Pre-hospital and intrahospital workflow optimization for patients with suspected ischemic stroke due to large vessel occlusion - findings from a tertiary care facility

BackgroundThe efficacy of recanalization treatment in patients with ischemic stroke due to large vessel occlusion (LVO) is highly time dependent. We aimed to investigate the effects of an optimization of prehospital and intrahospital pathways on time metrics and efficacy of endovascular treatment in ischemic stroke due to LVO.MethodsPatients treated with mechanical thrombectomy (MT) at the Hospital of St. John of God Vienna, Austria, between 2013 and 2020 were extracted from the Austrian Stroke Unit Registry. Study endpoints including time metrics, early neurological improvement and functional outcome measured by modified Rankin Scale (mRS) at 3 months were compared before and after optimization of prehospital and intrahospital pathways.ResultsTwo hundred ninety-nine patients were treated with MT during the study period, 94 before and 205 after the workflow optimization. Workflow optimization was significantly associated with time metrics improvement (door to groin puncture time 45 versus 31 min; p < 0.001), rates of neurological improvement (NIHSS ≥ 8: 30 (35%) vs. 70 (47%), p = 0.04) and radiological outcome (TICI ≥ 2b: 71 (75%) versus 153 (87%); p = 0.013). Functional outcome (mRS 0–2: 17 (18%) versus 57 (28%); p = 0.067) and mortality (34 (37%) versus 54 (32%); p = 0.450) at 3 months showed a non-significant trend in the later time period group.ConclusionThe implementation of workflow optimization was associated a significant reduction of intrahospital time delays and improvement of neurological and radiological outcomes.

Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry

BackgroundIntravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated...

Changes in blood gas values and electrolytes in the occluded artery predict outcomes after endovascular treatment in ischemic stroke

Background and purposeEndovascular treatment (EVT) is the best treatment for acute ischemic stroke with large vessel occlusion (LVO) and makes it possible to analyze the blood contents from the occluded vascular compartments. In this study, we attempted to evaluate regional changes in blood gas values and electrolytes in the occluded vessels, aiming to determine whether these changes can predict outcomes in LVO patients receiving EVT. Materials and methodsWe prospectively observed 45 consecutive ischemic stroke patients with LVO of the anterior circulation who underwent EVT. We collected the arterial blood proximal to the occlusion site before and after EVT, and the blood within the core of the occluded vascular compartment (distal to the thrombus) and evaluated the labs for blood gas values and electrolytes. Femoral samples were obtained under physiological flow conditions to represent systemic arterial blood. ResultsCompared with the femoral arterial blood samples, significant decreases in K+, Ca2+, HCO3−, BE, HCT, tHbc, and TCO2 levels were observed in the proximal luminal blood before EVT. Decreases in K+ and Ca2+ levels were also observed in the proximal luminal blood after EVT. Proximal/femoral ratio of pH and Na+ was associated with short-term clinical outcomes at 72 hours after EVT. A higher proximal/femoral Na+ ratio was associated with successful recanalization. Further analysis after propensity score matching showed significant changes in blood gas and electrolyte among different arterial locations in ICA and MCA LVO participants. Linear regression analyses indicated that the proximal/femoral ratio of pH, Na+, pCO2, HCO3, and TCO2 before EVT were associated with decrease in NIHSS score at 72 hours in ICA-LVO group. ConclusionsObvious changes in several parameters of arterial blood gas and electrolyte from the ischemic vasculature occur during hyperacute stroke. Proximal/femoral pH and Na+ ratio before EVT may be associated with short-term clinical outcome, which deserve to be further investigated.

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

Endovascular treatments for ischemic stroke

Highlights. Mechanical thrombectomy is the “gold standard” treatment of patients with large-vessel occlusions. Five randomized trials conducted in 2015 made a significant contribution to the development and introduction of mechanical thrombectomy into clinical practice. The DAWN and DEFUSE-3 trials have provided new insights into the pathophysiology of ischemic stroke and ensured the advancement in the therapeutic field.Abstract. Stroke is one of the leading causes of death and disability worldwide. The general strategy for the treatment of ischemic stroke is aimed at restoring blood flow to the ischemic regions of the brain. Intravenous thrombolysis has been the treatment for acute ischemic stroke since 1996. However, since 2015, as a result of 5 randomized trials, endovascular mechanical thrombectomy has become the gold standard for the treatment of patients with large cerebral artery occlusion. The DAWN and DEFUSE 3 trials have provided new insights into the pathophysiology of ischemic stroke, shifting the paradigm from “time = brain” to “collaterals = brain”. In this article, the authors will consider development of endovascular devices, modern mechanical thrombectomy techniques, and directions for further research of endovascular treatment for ischemic stroke.

Direct carotid artery puncture for acute ischemic stroke: Local experience and systematic review.

To establish surgical access during endovascular treatment of ischemic stroke, femoral artery puncture is most commonly performed followed by a small number of radial artery access procedures. However, there are few reports of carotid artery puncture. We report the case of an 87-year-old woman who was admitted to hospital with hemiplegia of the left limb and loss of consciousness for 40 min, accompanied by urinary incontinence. After complicated transfemoral and transradial attempts, the patient underwent emergency direct carotid artery puncture (DCAP) for the treatment of acute ischemic stroke. We reviewed the literature on this topic over a 7-year period (September 2014 to April 2022), including 202 patients with acute ischemic stroke who underwent emergency DCAP and endovascular surgery. The average age of these patients was 80.5 years. The left DCAP accounted for 52.5% (106/202) of the cases. Local anesthesia was utilized in 33.9% (64/189) of the cases. Angio-Seal was utilized for closure in 53.7% (79/147) of the patients. About half (105/199) of the patients recovered or improved their limb function after DCAP. Postoperative complications were mainly neck hematoma and one of these patients died due to a fatal neck hematoma. We describe the detailed procedure of the rare case of an emergency DCAP performed at our institution. DCAP provides an alternative treatment method in cases where thrombus removal access cannot be established through traditional methods.

Endovascular treatment for ischemic stroke with the drip-and-ship model-Insights from the German Stroke Registry.

BackgroundEndovascular therapy (EVT) in acute ischemic stroke has been widely established. Globally, stroke patients are transferred either directly to a thrombectomy center (DC) or a peripheral stroke unit with a “drip-and-ship” (DS) model. We aimed to determine differences between the DS and DC paradigms after EVT of acute stroke patients with large-vessel-occlusion (LVO) in the database of the German Stroke Registry (GSR).MethodsWe performed a retrospective analysis of GSR patients between June 2015 and December 2019 in 23 German centers. Primary outcome was an ordinal shift analysis of modified Rankin Scale (mRS) 90 days after index event. Secondary endpoints included time from symptom onset to recanalization and complications. Tertiary endpoint was the association of imaging strategies in DS admissions with outcome.Results2,813 patients were included in the DS and 3,819 in the DC group. After propensity score matching mRS after 90 days was higher in DS than DC admissions (OR 1.26; 95%-CI 1.13–1.40). Time from symptom-onset to flow-restoration was shorter in DC than DS (median 199.0 vs. 298.0 min; p < 0.001). DS patients undergoing magnetic resonance imaging (MRI; n=183) before EVT had a lower 90-day mRS than without (n = 944) (OR 0.63; 95%-CI 0.45–0.88). ASPECTS assessed on MRI correlated with 90-day mRS (ρ = −0.326; p < 0.001).ConclusionsClinical outcome was worse for EVT-eligible patients in the DS setting, even though patients were in a better state of health prior to stroke. A potentially mutable factor was the time delay of 99 min from symptom-onset to successful recanalization. Performing MRI before thrombectomy was associated with good outcome and MRI-ASPECTS was negatively correlated with mRS after 90 days.

Evaluation of CATCHVIEW Versus Standard Stent Retrievers for Endovascular Therapy: Results From the ETIS Registry

Background The CATCHVIEW device (Balt) is a last‐generation stent retriever designed for endovascular therapy. We aimed to compare the CATCHVIEW device with standard stent retrievers (SSRs) using propensity score methods and assess the noninferiority of CATCHVIEW versus SSRs. Methods We used the ETIS (Endovascular Treatment in Ischemic Stroke) multicenter (13 centers), prospective registry to compare clinical and radiological data of patients treated with CATCHVIEW or SSRs as a first‐line strategy. Procedural outcomes (successful, near‐perfect, perfect reperfusion after first‐line strategy, and at the end of endovascular therapy), clinical outcomes (modified Rankin Scale at 90 days), and safety outcomes (symptomatic intracranial hemorrhage, mortality at 90 days) were compared after propensity score matching. Noninferiority of CATCHVIEW was established if the prespecified lower bound of the 95% CI was &gt;−10%. Results From March 2017 to March 2020, 171 patients treated first‐line by CATCHVIEW were matched to 617 patients treated first‐line by an SSR. In the propensity score–matched cohort, successful reperfusion after first‐line strategy was achieved in 73.9% and 76.2% in the CATCHVIEW and SSR groups, respectively (absolute difference, −2.3%; 1‐sided 95% CI, −7.0% to ∞ ), demonstrating noninferiority of CATCHVIEW versus SSR. CATCHVIEW was associated with better near‐perfect (matched relative risk, 1.15; [95% CI, 1.00–1.31]) and perfect (matched relative risk, 1.26; [95% CI, 1.07–1.47]) reperfusion rates at the end of endovascular therapy and favorable 90‐day outcomes (matched relative risk, 1.27; [95% CI, 1.03–1.55]). Safety outcomes were comparable. Conclusions In this propensity score–matched cohort, we demonstrated the noninferiority of CATCHVIEW compared with SSR, as the first‐line strategy for successful reperfusion. CATCHVIEW achieved higher reperfusion rates at the end of endovascular therapy and higher rates of favorable outcomes at 90 days.

Clinical case of endovascular treatment of ischemic stroke after carotid endarterectomy

The article presents a clinical case of endovascular treatment practice of a patient after carotid endarterectomy complicated by ischemic stroke. It is pointed out that early diagnosis allows well-timed detection of complications in the postoperative period and timely selection of treatment methods. The method of intravascular thromboectomy, which significantly reduces the onset of complications in the first hours after surgery, is described in detail. The tactics of management of patients with acute disorders of cerebral circulation during operations on brachiocephalic arteries are analyzed.

Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study.

Background:Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.Methods:We retrospectively analyzed data from the Dutch MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and MR CLEAN registry. We included adult patients with a large vessel occlusion in the anterior circulation who underwent endovascular treatment within 6.5 hours of stroke onset. We used univariable and multivariable logistic regression analyses to identify determinants of overall sICH occurrence, sICH within infarcted brain tissue, and sICH outside infarcted brain tissue.Results:SICH occurred in 203 (6%) of 3313 included patients and was located within infarcted brain tissue in 50 (25%), outside infarcted brain tissue in 23 (11%), and both within and outside infarcted brain tissue in 116 (57%) patients. In 14 patients (7%), data on location were missing. Prior antiplatelet use, baseline systolic blood pressure, baseline plasma glucose levels, post-endovascular treatment modified treatment in cerebral ischemia score, and duration of procedure were associated with all outcome parameters. In addition, determinants of sICH within infarcted brain tissue included history of myocardial infarction (adjusted odds ratio, 1.65 [95% CI, 1.06–2.56]) and poor collateral score (adjusted odds ratio, 1.42 [95% CI, 1.02–1.95]), whereas determinants of sICH outside infarcted brain tissue included level of occlusion on computed tomography angiography (internal carotid artery or internal carotid artery terminus compared with M1: adjusted odds ratio, 1.79 [95% CI, 1.16–2.78]).Conclusions:Several factors, some potentially modifiable, are associated with sICH occurrence. Further studies should investigate whether modification of baseline systolic blood pressure or plasma glucose level could reduce the risk of sICH. In addition, determinants differ per location of sICH, supporting the hypothesis of varying underlying mechanisms.Registration:URL: https://www.isrctn.com/; Unique identifier: ISRCTN10888758.

Abstract 258: Prehospital Transport Protocol For Comprehensive Stroke Center Triage Is Associated With Reduced Last KnownWell To Arrival Times For Intracranial Hemorrhage

Title: Prehospital Transport Protocol for Comprehensive Stroke Center Triage is Associated with Reduced Last Known Well to Arrival Times for Intracranial Hemorrhage Background: In September 2018, we implemented a prehospital routing protocol for patients with suspected severe stroke and large vessel occlusion using the 3 Item Stroke Scale (3I-SS). Patients who have a 3I-SS score of ≥4 and have a known last normal time of ≤6 hours were transported to the closest Comprehensive Stroke Center (CSC). While the impact on endovascular treatment for ischemic stroke is more established, the effect of this transport policy on patients with intracerebral hemorrhage (ICH) is unknown. Objective/Methods: The objective of the study was to determine if implementation of a regional CSC transport protocol reduced last known well (LKW) to hospital arrival time for patients with ICH. Data was retrospectively reviewed all patients with a primary diagnosis of ICH from Get With The Guidelines®(GWTG) Stroke regional registry between January 2018 to May 2019 (8 month pre and 8 months post-implementation) and consisting of 16 Primary Stroke Centers (PSCs) and 8 CSCs. We analyzed LKW-arrival times to compare median times in the pre- vs. post-implementation periods. Results: There were 501 ICH cases in the pre-implementation period (mean age 66, 43.3% Black, and 52.3% male) and 548 in the post-implementation period (mean age 66, 41.0% Black, and 54.3% male). In the post-implementation period, median LKW to hospital arrival time was 255 minutes vs. 270.5minutes in the pre-implementation period (P value 0.029). LKW to hospital arrival times for those patients arriving from EMS decreased from a median 112.5 minutes to 81 minutes (P value 0.034). Conclusions: A prehospital direct-to-CSC transport protocol resulted in a substantial decrease in the median LKW to hospital arrival times for ICH patients, driven especially by EMS-arriving patients. Prehospital protocols could increase access to time sensitive life-saving therapies for ICH.

Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion

BackgroundThe number of mechanical thrombectomy (MT) passes is strongly associated with angiographic reperfusion as well as clinical outcomes in patients with anterior circulation ischemic stroke. However, these associations have not...

Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

BackgroundEndovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the incidence and predictors...

Endovascular treatment of ischemic stroke due to isolated internal carotid artery occlusion: ETIS registry data analysis.

The best treatment for acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (CICAO) (i.e., without associated occlusion of the circle of Willis) is still unknown. In this study, we aimed to describe EVT safety and clinical outcome in patients with CICAO. We analyzed data of all consecutive patients, included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry between 2013 and 2020, who presented AIS and proven CICAO on angiogram and underwent EVT. We assessed carotid recanalization, procedural complications, National Institutes of Health Stroke Scale (NIHSS) at 24h post-EVT, and 3-month favorable outcome (modified Rankin Scale, mRS ≤ 2 or equal to the pre-stroke value). Forty-five patients were included (median age: 70years; range: 62-82years). The median NIHSS before EVT was 14 (9-21). Carotid stenting was performed in 23 (51%) patients. Carotid recanalization at procedure end and on control imaging was observed in 37 (82%) and 29 (70%) patients, respectively. At day 1 post-EVT, the NIHSS remained stable or decreased in 25 (60%) patients; 12 (29%) patients had early neurologic deterioration (NIHSS ≥ 4 points). The rate of procedural complications was 36%, including stent thrombosis (n = 7), intracranial embolism (n = 7), and symptomatic intracranial hemorrhage (n = 1). At 3months, 18 (40%) patients had a favorable outcome, and 10 (22%) were dead. Our study suggests that EVT in AIS patients with moderate/severe initial deficit due to CICAO led to high rate of recanalization at day 1, and a 40% rate of favorable outcome at 3months. There was a high rate of procedural complication which is of concern. Randomized controlled trials assessing the superiority of EVT in patients with CICAO and severe deficits are needed.

Effect of intravenous thrombolysis before endovascular therapy on outcome according to collateral status: insight from the ETIS Registry

BackgroundIt is unknown whether collateral status modifies the effect of pretreatment intravenous thrombolysis (IVT) on the outcomes of patients with large vessel occlusions treated with endovascular therapy (EVT). We aimed...

Abstract TMP63: Predictors And Clinical Impact Of ASPECTS Evolution After Successful Reperfusion With Endovascular Therapy: Insight From The ETIS Registry

Background: Alberta Stroke Program Early CT scan Score (ASPECTS) is a reliable imaging biomarker of infarct extension in patients with large vessel occlusions. ASPECTS evolution, a surrogate of infarct expansion, is an important predictor of functional and safety outcomes after endovascular therapy (EVT). In this study, we aimed to identify the predictors of ASPECTS evolution after successful reperfusion and the association between ASPECTS evolution and outcomes of EVT. Methods: We used data from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke (ETIS) registry (NCT03776877). For the purpose of this study, we enrolled patients with anterior circulation LVO treated with EVT and achieved successful reperfusion (mTICI 2b-3). Additional inclusion criteria included 1) the availability of ASPECTS score on admission and at 24 hours after EVT 2) ASPECTS was assessed on the same imaging technique (i.e MRI or CT) on admission and at 24 hours. We considered 2 or more points decrease in ASPECTS as a significant ASPECTS change. Multivariable logistic regression analyses were used to identify the predictors of ASPECT evolution and to study the association between ASPECTS evolution and outcomes. Results: We included a total of 1161 patients, of whom 978 (84%) patients had at least 2 points decrease in ASPECTS score. Worsening ASPECTS score was associated with higher odds of poor functional outcome (90-day mRS 3-6), mortality, and symptomatic intracerebral hemorrhage. Admission ASPECTS, NIHSS, blood glucose, location of occlusion, final mTICI score, total number of attempts and procedure time emerged as predictors of ASPECTS evolution. Conclusion: ASPECTS evolution is a strong predictor of clinical and safety outcomes after successful reperfusion with EVT.

Abstract TP135: Prehospital Transport Protocol For Comprehensive Stroke Center Triage Is Associated With Reduced Last Known Well To Arrival Times For Intracranial Hemorrhage

Background: In September 2018, we implemented a prehospital routing protocol for patients with suspected severe stroke and large vessel occlusion using the 3 Item Stroke Scale (3I-SS). Patients who have a 3I-SS score of ≥4 and have a known last normal time of ≤6 hours were transported to the closest Comprehensive Stroke Center (CSC). While the impact on endovascular treatment for ischemic stroke is more established, the effect of this transport policy on patients with intracerebral hemorrhage (ICH) is unknown. Objective/Methods: The objective of the study was to determine if implementation of a regional CSC transport protocol reduced last known well (LKW) to hospital arrival time for patients with ICH.Data was retrospectively reviewed all patients with a primary diagnosis of ICH from Get With The Guidelines® (GWTG) Stroke regional registry between January 2018 to May 2019 (8 month pre and 8 months post-implementation) and consisting of 16 Primary Stroke Centers (PSCs) and 8 CSCs. We analyzed LKW-arrival times to compare median times in the pre- vs. post-implementation periods. Results: There were 501 ICH cases in the pre-implementation period (mean age 66, 43.3% Black, and 52.3% male) and 548 in the post-implementation period (mean age 66, 41.0% Black, and 54.3% male). In the post-implementation period, median LKW to hospital arrival time was 255 minutes vs. 270.5 minutes in the pre-implementation period (P value 0.029). LKW to hospital arrival times for those patients arriving from EMS decreased from a median 112.5 minutes to 81 minutes (P value 0.034). Conclusions: A prehospital direct-to-CSC transport protocol resulted in a substantial decrease in the median LKW to hospital arrival times for ICH patients, driven especially by EMS-arriving patients. Prehospital protocols could increase access to time sensitive life-saving therapies for ICH.

Impact of Number of Passes Before Rescue Therapy in Thrombectomy for Basilar Artery Strokes

Background When standard endovascular thrombectomy techniques fail to achieve a successful recanalization, it is often necessary to use rescue therapies (RTs). RTs are more commonly used in basilar artery occlusions and conventionally thought to represent “a last resort option.” We sought to study the outcomes of basilar artery occlusion patients who received RT, and further hypothesize that the number of instrumental passes before initiation of RT may be associated with increased risk for poor clinical outcomes. Methods We performed a retrospective analysis of the ETIS (“Endovascular Treatment in Ischemic Stroke”) registry. Our primary analysis included 277 patients who underwent thrombectomy for basilar artery occlusion, of whom 74 patients (26.7%) who received RT, defined as the use of intra‐arterial drugs, angioplasty, or stenting. Primary outcome measures included successful or complete reperfusion (final modified thrombolysis in cerebral infarction ≥2b or 3), functional independence (modified Rankin scale of 0–2), and mortality at 3 months. Results RT patients were more likely to have an atherosclerotic cause than non‐RT patients (46/74 [62.2%] versus 38/203 [18.7%]), were more likely to die (42/74 [56.8%] versus 73/203 [36.0%]), and were less likely to achieve functional independence (12/74 [16.2%] versus 84/203 [41.4%]). In the RT cohort, 17 of 74 patients (23.0%) had 1 pass before RT initiation, and 8 of 17 (47.1%) achieved a modified Rankin scale score of 0 to 2 at 3 months, with a mortality rate of 23.5% (4/17). The chance of achieving good clinical outcome decreased with each additional pass, whereas mortality increased. The odds of mortality at 3 months were highest in the &gt;3 passes group, with an odds ratio of 10.29 (95% CI, 2.42–43.81) compared with 1 pass. None of the 25 patients with &gt;3 passes before RT achieved 3‐month functional independence. Conclusions There is a significant correlation between the number of passes before initiation of RT and 3‐month clinical outcomes in basilar artery occlusion patients.

Hospital Variation in Time to Endovascular Treatment for Ischemic Stroke: What Is the Optimal Target for Improvement?

BackgroundTime to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between‐hospital and within‐hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door‐to‐reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation.Methods and ResultsWe used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door‐to‐reperfusion time was subdivided into time intervals, separately for direct patients (door‐to‐computed tomography, computed tomography‐to‐computed tomography angiography [CTA], CTA‐to‐groin, and groin‐to‐reperfusion times) and for transferred patients (door‐to‐groin and groin‐to‐reperfusion times). We used linear mixed models to distinguish the variation in door‐to‐reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between‐hospital variation in door‐to‐reperfusion time was 9%, and the within‐hospital variation was 91%. The contribution of case‐mix variables on the variation in door‐to‐reperfusion time was marginal (2%–7%). Of the between‐hospital variation, CTA‐to‐groin time explained 83%, whereas groin‐to‐reperfusion time explained 15%. Within‐hospital variation was mostly explained by CTA‐to‐groin time (33%) and groin‐to‐reperfusion time (42%). Similar results were found for transferred patients.ConclusionsDoor‐to‐reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between‐hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA‐to‐groin time and groin‐to‐reperfusion time.