Background and Purpose— Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes. Methods— US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. Direct EVT-access, defined as the population with the closest facility being an EVT-center, was calculated from validated trauma-models adapted for stroke. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model-A used a greedy algorithm to capture the largest population with direct access when flipping 10% and 20% non-EVT to EVT-centers to maximize access. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center. Results— Of 1941 stroke-centers, 713 (37%) were EVT. Approximately 61 million (19.8%) Americans have direct EVT access within 15 minutes while 95 million (30.9%) within 30 minutes. There were 65 (43%) EVT centers in TX with 22% of the population currently within 15-minute access. Flipping 10% hospitals with top population density improved access to 30.8%, while bypassing resulted in 45.5% having direct access to EVT centers. Similar results were found in NY (current, 20.9%; flipping, 34.7%; bypassing, 50.4%), CA (current, 25.5%; flipping, 37.3%; bypassing, 53.9%), and IL (current, 15.3%; flipping, 21.9%; bypassing, 34.6%). Nationwide, the current direct access within 15 minutes of 19.8% increased by 7.5% by flipping the top 10% non-EVT to EVT-capable in all states. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage. Conclusions— EVT-access within 15 minutes is limited to less than one-fifth of the US population. Optimization methodologies that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT-access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT-access.
BackgroundSex disparities in acute ischemic stroke outcomes are well reported with IV thrombolysis. Despite several studies, there is still a lack of consensus on whether endovascular thrombectomy (EVT) outcomes differ between men and women.ObjectiveTo compare sex differences in EVT outcomes at 90-day follow-up and assess whether progression in functional status from discharge to 90-day follow-up differs between men and women.MethodsFrom the Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) prospective cohort study (2016–2018), adult men and women (≥18 years) with anterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery M1/M2) treated with EVT up to 24 hours from last known well were matched using propensity scores. Discharge and 90-day modified Rankin Scale (mRS) scores were compared between men and women. Furthermore, we evaluated the improvement in mRS scores from discharge to 90 days in men and women using a repeated-measures, mixed-effects regression model.ResultsOf 285 patients, 139 (48.8%) were women. Women were older with median (IQR) age 69 (57–81) years vs 64.5 (56–75), p=0.044, had smaller median perfusion deficits (Tmax >6 s) 109 vs 154 mL (p<0.001), and had better collaterals on CT angiography and CT perfusion but similar ischemic core size (relative cerebral blood flow <30%: 7.6 (0–25.2) vs 11.4 (0–38) mL, p=0.22). In 65 propensity-matched pairs, despite similar discharge functional independence rates (women: 42% vs men: 48%, aOR=0.55, 95% CI 0.18 to 1.69, p=0.30), women exhibited worse 90-day functional independence rates (women: 46% vs men: 60%, aOR=0.41, 95% CI 0.16 to 1.00, p=0.05). The reduction in mRS scores from discharge to 90 days also demonstrated a significantly larger improvement in men (discharge 2.49 and 90 days 1.88, improvement 0.61) than in women (discharge 2.52 and 90 days 2.44, improvement 0.08, p=0.036).ConclusionIn a propensity-matched cohort from the SELECT study, women had similar discharge outcomes as men following EVT, but the improvement from discharge to 90 days was significantly worse in women, suggesting the influence of post-discharge factors. Further exploration of this phenomenon to identify target interventions is warranted.Trial registration numberNCT02446587.
Introduction: Females are underrepresented as speakers at major scientific conferences. Furthermore, in neurology, males outnumber females in academic positions, rank and number of publications, which may influence this inequality. Objective: To evaluate trends in invited speakers by sex at the International Stroke Conference (ISC). Methods: Data were obtained (years 2014-2018) for invited speakers to the ISC from the American Heart Association. Variables included sex, degree, race, speaker institution country, and speaker category. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression. Results: Over 5 years, 1086 individuals with 1283 presentations were invited for invited symposia (83%), pre-conference (11%), debate (5%), and case theater (1%). Females represented a mean of 29% of speakers, which did not vary by year (p=0.99), so years were combined. The highest and lowest proportions of females were in invited symposia (30.4%) and case theater (5.6%). All mid-levels and nurses, but only 17.7% of physician speakers were female. Females were 32.7% of Caucasian speakers and only 16.7% and 12.0% of Black and Hispanic speakers, respectively. The highest and lowest proportions of female speakers were from institutions in South America (50%) and Africa (0%). The proportion of female speakers was highest in nursing (86.4%) and pediatric stroke (45.2%) and lowest in neurocritical care and aneurysm (0%). Grouped, the highest proportion of female speakers was in recovery and rehabilitation (33.5%), and the lowest was in acute care (19%). Males were more likely invited as speakers more than once (p=0.01). Conclusions: Females are less likely invited speakers to the ISC compared to males, especially in fields like critical care, with a smaller female pool. Moreover, females in underrepresented racial groups and female physicians are less often speakers. Increased efforts are warranted to improve sex differences among speakers at the ISC.
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