Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

Abstract

Background: Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a “hub-and-spoke” model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the “hub-and-spoke” model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems. Methods: We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the “hub-and-spoke” model. Good clinical outcome was defined as modified Rankin Scale 0–2 and the difference between the 2 groups was tested by logistic regression. Results: Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58–77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48–77%) achieved good clinical outcomes compared to 52% (95% CI 43–61%) in the “hub-and-spoke” group (p = 0.233). Conclusion: This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with “hub-and-spoke” service delivery.

Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

“…34 During the COVID-19 pandemic, there will be new challenges in triaging stroke patients with suspected or confirmed COVID-19 infection, who cannot be transferred rapidly to angiographic suite from ED or from outside the hospital due to added requirements. Inter-facility transfer, which occurs in 44%-72% of acute ischemic stroke patients 41,42 may require special equipment and personnel that are likely to delay the procedure. Due to expected challenges, intravenous rt-PA in an isolation ward, rather than percutaneous coronary intervention has been recommended for patients with acute myocardial infarction.…”

Mothership versus Drip-and-Ship Model for Mechanical Thrombectomy in Acute Stroke: A Systematic Review and Meta-Analysis for Clinical and Radiological Outcomes

“…Systematic search retrieved 18 studies including 7,017 patients (PRISMA flowchart) ( Figure 1). [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Most of the included studies were observational and prospective, only one study was a RCT 15 (Table 1). As a result, quality of studies ranged fair to good, with only one RCT achieving optimal score on risk of bias assessment.…”

“…Systematic search retrieved 18 studies including 7,017 patients (PRISMA flowchart) ( Figure 1 ) [ 10 - 27 ]. Most of the included studies were observational and prospective, only one study was a RCT [ 15 ] ( Table 1 ).…”

Impact of interhospital transfer on patients undergoing endovascular thrombectomy for acute ischaemic stroke in an Australian setting

“…It was based on a retrospective analysis of prospectively collected data from a single centre, which limits applicability to regions with different geography and population density. We did not analyse patient outcomes according to treatment during business hours versus after hours, which has been shown to influence workflow time metrics 9. Although there was no difference in baseline characteristics between transferred and direct presenter groups, we cannot exclude a (favourable or unfavourable) selection bias in transferred patients.…”

“…An Australian study based in Victoria found no difference in 90-day functional outcomes between transferred and direct to CSC presenters undergoing EVT9; however, international registries have demonstrated poorer outcomes in transferred patients 10–12. New South Wales and other Australian states have different geographical challenges from Victoria.…”