ABSTRACT NUMBER: ESOC2026A1329 TIME TO ENDOVASCULAR TREATMENT IN MEDIUM OR DISTAL VESSEL OCCLUSION STROKE: A SECONDARY ANALYSIS OF THE DISTAL TRIAL

Abstract Background and aims Endovascular treatment (EVT) has not shown to improve functional outcomes over best medical treatment (BMT) alone in stroke patients with medium or distal vessel occlusions (MDVO). Whether time to treatment modifies the treatment effect of EVT is uncertain. Methods This post-hoc analysis of the DISTAL trial included 543 patients. Adjusted mixed-effects ordinal regression models were used to test the interaction of allocation to EVT plus BMT versus BMT and time to treatment (hours) regarding 90-day modified Rankin Scale (mRS) scores. Time to treatment was defined as last-seen-well to arterial puncture in EVT patients, or last-seen-well to randomization plus the trial’s mean randomization-to-puncture time (for BMT patients). Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and death. Furthermore, the effect of time to treatment alone, without additional moderation by treatment arm was assessed. For EVT patients, in-hospital time intervals (admission-to-arterial-puncture, imaging-to-arterial-puncture) were assessed. Results Neither evidence of effect modification by time to treatment for mRS (interaction cOR per hour 1.02, 95% CI 0.97–1.07), sICH (OR 0.95, 0.81–1.14), or death (OR 0.92, 0.84–1.01) nor an overall effect of time to treatment on outcome (OR 0.99, 0.96–1.02) was observed. Within the EVT group, admission-to-arterial-puncture and imaging-to-arterial-puncture time were not associated with functional outcomes (OR 0.84, 0.63–1.12, and OR 1.06, 0.76–1.53, respectively). Conclusions Overall time to treatment did not modify the treatment effect of EVT versus BMT in stroke patients presenting with MDVO. Conflict of interest JK reports a research grant from Boehringer-Ingelheim (Ingelheim am Rhein, Germany) supporting the IRIS collaboration and the TECNO trial, financial support within a research agreement with Siemens (Forchheim, Germany) related to flat-panel imaging, research support by Le Studium (Orleans, France) for a research fellowship in Tours (France), a research collaboration without financial compensation with Cercare Medical (Copenhagen, Denmark), a research grant from the Bangerter-Rhyner foundation (Bern, Switzerland) supporting a project on individualized decision making on intravenous thrombolysis, a research grant from the Swiss Heart Foundation (Bern, Switzerland) supporting the Prediction of Delayed Reperfusion using Flatpanel imaging and research grants from the Swiss National Science Foundation (Bern, Switzerland) supporting the TECNO and DO-IT trial, a research grant from the Medical Faculty of the University of Bern within the of the research excellence program, as well as a research grant provided by the Horten Foundation (Zurich, Switzerland) to support the DO-IT trial; all fees are paid to the institution. MP received research grants from the Swiss National Science Foundation (SNF) and Bangerter-Rhyner Stiftung, received unrestricted grant support from Medtronic Inc., Rapid Medical Inc., Penumbra Inc., Siemens Healthineers AG, Stryker Neurovascular Inc., Phenox GmbH (paid to institution), received speaker fees from Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Rapid Medical Inc., Siemens Healthineers AG (paid to institution) and is Sponsor-PI of the DISTAL Trial, SPINNERS Trial, ICARUS Trial. UF reported research support of the Swiss National Science Foundation and the State Secretariat for Education, Research and Innovation; research support of the Swiss Heart Foundation, the Swiss Brain League and the Horton Foundation; research grants from Medtronic and from Stryker, Rapid medical, Penumbra, Medtronic and Phenox, Boehringer Ingelheim; consultancies for Medtronic, Bayer, Boehringer Ingelheim, Boston Scientific, CSL Behring, Merck, Siemens and Takeda (fees paid to institution). Participation in an advisory board for AstraZeneca (former Alexion/Portola), Auzone, Biogen, AbbVie, Siemens, Corxel (fees paid to institution). Member of a clinical event committee (CEC) of the COATING study (Phenox). Member of the data and safety monitoring committee (DSMB) of the TITAN, RESCIND, LATE_MT, IN EXTREMIS and RapidPulse trials. Past president of the Swiss Neurological Society and president-elect of the European Stroke Organisation. VA, AB and NR have nothing to disclose.