Impact of time from symptom onset to recanalization in acute anterior circulation large vessel occlusive stroke with same tissue window: A patient-level pooled analysis of the three randomized controlled trials

Although multimodal imaging extends the thrombectomy window to 24 h based on tissue viability, the prognostic value of shorter onset-to-recanalization times within this window is unclear. Using pooled trial data, we assessed this association in patients meeting Alberta Stroke Program Early CT Score ASPECTS ≥6. We conducted a patient-level pooled analysis of three multicenter randomized trials: DEVT, RESCUE BT, and MARVEL. Multivariable analysis was conducted to evaluate the association between the time from symptom onset to recanalization and 90-day functional independence (modified Rankin Scale mRS score of 0-2 and 0-1), any intracranial hemorrhage, and 3-month mortality. Restricted cubic splines were used to model the continuous relationship and identify optimal time thresholds. Among 1931 patients, a shorter onset-to-recanalization time was independently associated with better outcomes. Compared to the >6-12 h and >12-24 h intervals, recanalization within ≤6 h was associated with higher odds of mRS 0-2 (adjusted odds ratio OR 0.66, 95% CI 0.53-0.82, p 6-12 h window was associated with increased mortality (adjusted OR 1.53, 95% CI 1.02-2.28, P = 0.04) and symptomatic intracranial hemorrhage (adjusted OR 1.66, 95% CI 1.32-2.09, p < 0.01). Our analysis revealed a more pronounced association between onset-to-recanalization time and 90-day functional outcomes than previously recognized. Among patients with ASPECTS ≥6 undergoing thrombectomy, expedited treatment was strongly linked to substantially improved neurological recovery.