Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia
Authors: García-Tornel Álvaro , Flores Alan , Terceño Mikel , Cardona Pedro , Amaro Sergi , Gomis Meritxell , Zaragoza Josep , Krupinski Jerzy , Gómez-Choco Manuel , Mas Natalia , Cocho Dolores , Catena Esther , Purroy Francesc , Deck Matias , Rubiera Marta , Pagola Jorge , Rodriguez-Luna David , Juega Jesús , Rodríguez-Villatoro Noelia , Molina Carlos A. , Soro Cristina , Jimenez Xavier , Salvat-Plana Mercè , Dávalos Antoni , Jovin Tudor G , Abilleira Sonia , Pérez de la Ossa Natalia , Ribó Marc , Sanjuan Estela , Santana Katherine , Maisterra Olga , Santamarina Estevo , Muchada Marian , Boned Sandra , Franco Antonio Palasi , Gadea Marta Olivé , Deck Matías , Requena Manuel , Sala Victoria , Muñoz Lucía , Millán Mónica , López-Cancio Elena , Dorado Laura , Hernández-Pérez María , Ciurans Jordi , Samaniego Daniela , Canento Tamara , Martin Lorena , Planas Anna , Broto Joaquin , Sorrentino Agustín , Paré Martí , Zhu Nuole , Garrido Alicia , Grau Laia , Crespo Ane Miren , Presas Silvia , Almendrote Miriam , Ramos Alba , Lucente Giuseppe , Ispierto Lourdes , Lozano Manuel , Becerra Juan Luis , Jiménez Marta , Rolán Dolores Vilas , Guanyabens Nicolas , Sanchez-Ojanguren Josep , Martínez-Piñeiro Alicia , Forcén Sara , Gea Mireia , Álvarez Marta , Ramos Anna , Lizarbe Manuel Domínguez , Guerra Rubio , Bragado Irene , Arbex Andrea , Rodríguez Luis , Bustamante Alejandro , Portela Pere Cardona , García Helena Quesada , Rodríguez Blanca Lara , Cayuela Nuria , Miró Julia , Marzal Clara , Paipa Andrés , Campoy Sergio , Núñez Ana , Arroyo Pablo , Besora Sarah , Adell Vanessa , Campdelacreu Jaume , Martí Montse Alemany , González Belén , Vila Laura Bau , Crespo Marta Fiter , Berbel Anna , Urbaneja Ma. Cristina Villaescusa , Guillen Núria , Vidal Nuria , Santamaria Patricia Valentina Vérez , Navarro Diego Herrero , Simó Marta , Falip Mercedes , Matas Elisabeth , Ochoa Neus Mongay , Gifreu Ariadna , Muñoz Albert , Romero Lucía , Portell Eduard , Perez Guillermo Hernández , Esteve F. Ruiz , Teixidor Silvia , Talavera Augusto Salazar , Gómez Roser , Nuin Xabier Urra , Vargas Martha , Chamorro Ángel , Llull Laura , Renú Arturo , Rudilosso Salvatore , del Valle Raquel Sánchez , Ariño Helena , Solà Nuria , la Puma Delón , Gil Francisco , Gómez Juan Bernardo , Matos Nuria , Falgàs Neus , Borrego Sergi , Sánchez Almudena , Balasa Mircea , Montejo Carmen , Guasp Mar , Reyes David , Cervilla Pablo Sánchez , Contador Jose Miguel , Monge Victor Augusto Vera , Ramos Oscar , Rodríguez Alejandro , Campello Ana Rodríguez , Ballester Gemma Romeral , Trujillano Mireia Llop , Steinhauer Eva Giralt , Godia Elisa Cuadrado , Santiago Angel Javier Ois , Conde Jordi Jimenez , Fábregas Joan Martí , Guisado Daniel , Prats Luís , Camps Pol , Delgado Raquel , Domeño Alejandro Martínez , Marín Rebeca , Cànovas David , Estela Jordi , Ros Marta , Aranceta Sonsoles , Espinosa Jordi , Rubio Marta , Lafuente Cristina , Barrachina Oriol , Anguita Alicia , Reverter Anna , García Carmen , Sansa Gemma , Hervas Mariona , Crosas Monica , Delgado Tania , Folch Dra Sonia Huertas , Gamito Gemma Muñoz , Alvarez Josep Trenado , Subirana Teresa , Molina Jessica , Besora Sarah , Romero Laura Comes , Valls Gemma Guardia , Jover Miriam , Sotova Javier Joaquín , García Sánchez Sonia Mª , Valenzuela Sebastian , Mengual Juan José , Font M. 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, Esparza Torres , Blanco Vazquez , De la Paz Vazquez , Gil Vazquez , Gonzalez Vazquez , Meler Vidal , Cots Vilalta , Jimenez Vilches , Jose Maria , Fernandez Visser , Gavin Viu , Vives Vives , Jimenez Carmona , Jose Francisco , Vilches Galobardes , Gomez Gonzalez , Manzanera Jodar , Cortes Marimon , Orive Marrodan , Bosch Martin , Jose Maria , Lopez Martorell , Roca Millares , Jesus M , Guri Miralles , Hernandez Muliterno , Oliva Muñoz , Pujol Pons , Conde Postius , Arruñada Prieto , Antonio Jose , Mathé Quintana , Mata Rosell , Alvarez Aguirre , Alvarez Alvarin , Flores Arrufat , Pago Bañuelos , Andreu Burnat , Vilar Campo , Hidalgo Cardus , Gil Castello , Gloria Maria , Montsesinos Castrillo , Estopà Català , Garces Clave , Sanroma Comes , Sequi Descalzo , Ricol Errando , Campillo Escudero , del Mar Maria , Alvarez Fernandez , Gomez Fernandez , Perez Fernandez , Espinosa Franch , Graells Freixes , Plaza Garcia , Gallego Garcia-Marron , Simancas Hernandez , Covas Homar , Royo Huerta , Armas Jaraba , Ramos Jimenez , Canela Lopez , Angeles M , Lopez Lopez , Oganissian Lopez , Romero Madrona , Rosa M , Millan Martinez , Morón Martínez , Encinas Merchan , Fornieles Morell , Jimenez Moreno , Rico Muñoz , Rodriguez Navarro , Ibañez Nogales , Maria Rita , Viera Novillo , Torrabadella Parella , Alba Mari , Villar Pera , Montserrat Carla , Carbonell Puertas , Miralles Rabella , Trilles Ramis , Ortiz Ribera , Fuertes Rodriguez , Gonzalez Sanchez , Perez Sastre , Perez Segura , Borrega Soro , Garcia Soto , Angeles Maria , Fores Tapia , Bernad Tellez , Alvarez Trenado , Moreda Español , Martin Felix , Perez Herrero , Manzanera Jodar , Fuster Lanau , Gomariz Lopez , Orive Marrodan , Bosch Martin , Jose Maria , Guri Miralles , Oliva Muñoz , Lozano Pardo , Pujol Pons , Altimiras Quintana , Lopez Ventosa , Damian Almodovar , Colino Alvarez , Monterroso Alvarez , Comas Arambudo , Garzon Boullon , Capella Burgos , Garcia Campuzano , Del Mar Maria , Olivas Capdevila , Fernandez Carcelen , Solà Caro , Marti Carre , Isabel Clara , Bacaicoa Carretero , Gil Castello , Gloria Maria , Montsesinos Castrillo , Calderon Cazorla , Osuna Chacon , Planas Cortes , Olio Cortit , Estany Delhomme , Carasso Duran , Javier Pablo , Campillo Escudero , del Mar Maria , Martinez Fructuos , Lopez Garcia , Luis Pascual , Plaza Garcia , Vallve Genis Amill , Arroyo Gomez , Girbau Gomez , Muñoz Gonzalez , Ventura Hernaez , Covas Homar , Gimenez Lavernia , Rojo Martin , Medina Martínez , Millan Martinez , Barrera Mayol , Pi Mercader , Dalmau Merino , Campodarbe Miguel , Pastalle Montserrat Puig , de la Cruz Morales , Fornieles Morell , Sanchez Moreno , Javier Francisco , Reig Pallares , Torrabadella Parella , Alba Mari , Barrameda Penela , Ajenjo Prieto , Benavente Rebollar , Pareja Rodriguez , Piñar Rodríguez , Javier Francisco , Tello Rodriguez , Pereda Romero , Saborido Sainz , Martin Santacana , Martinez Santos , Chavez Sierra , Testa Toledo , Figueras Tomàs , Garcia Torres , José Pedro , Torres Turbau , Domenech Vicente , Esteo Villena , Pertegaz Vives , Gonzalez Baena , Pont Bagaria , Sanchez Beltran , Alarcon Bonet , Ballescà Borch , Clanchet Buhils , Garcia Closa , Carril Colomina , Sanchez Cristina Fernandez , Toledo Edurne Judith Fernandez , Rodriguez Espases , Resa Espert , Xavier F , Sol Fernández , Lugo Gonzalez , Llesera Gracia , Lendinez Herrada , Liesa Juliench , Alicia Sandra , Ortega Lopez , Yuste Lopez , Villanueva Lozano , Soto Lucia Sola , Castellano Madrid , Cano Megias , Jesus Daniel , Ponce Montasell , Sospedra Montesinos , Martinez Moya , Herrera Muñoz , Isabel M , Fernandez Ocaña , Jose Maria , Bernal Palau , Sole Perez , Carbonell Ramon , Lop Ribas , López Rubio , Lopez Rueda , Castaño Sabat , Lara Sabata , Ramírez Salmerón , Gornals Sebastia , Creus Serra , Dalmau Serrano , Mainero Sumasi , Gabriel Gonzalo , Masa Torello , Primo Valencia , Muñoz Ana Maria Viñuales , Roig Josep , Hidalgo Verònica 
Published: February 2023

Background:
We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020.

Methods:

We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00
am
–8:59
pm
) and nighttime (9:00
pm
–7:59
am
). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated.

Results:

We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163];
P
interaction
=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ;
P
interaction
<0.01); no heterogeneity was observed for other stroke subtypes (
P
interaction
>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers.

Conclusions:
Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome.

Registration:

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02795962.