Field triage for endovascular stroke therapy: a population-based comparison

Abstract

BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.

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.…”

Stroke Treatment Delay Limits Outcome After Mechanical Thrombectomy: Stratification by Arrival Time and ASPECTS

“…In addition, the door in to door out times for patients being transferred should be further evaluated and informed by outcome trends in early presenting patients 15,16 . Recent observational studies have shown that bypassing primary stroke centers for patients with suspected LVO in the field leads to shorter treatment times and better outcomes 17 . Moreover, future research in neuroprotection such as with cooling, vasopressors, or other neuroprotective agents should target early presenting patients with favorable imaging profiles, in whom even small delays may impact functional outcome.…”

Strategies to reduce the impact of demand for concurrent endovascular thrombectomy

“…Increased EVT volumes at qualified centers due to greater availability of treatment, refined stroke systems of care, and expanding treatment indications is expected to increase the probability of being faced with multiple patients with concurrent need for time sensitive treatment 2 4 6 10. Such simultaneous presentations may exceed capacity of a single neurointerventional team and result in a clinically detrimental delay of care.…”

“…Stroke treatment has been revolutionized by the advent of endovascular thrombectomy (EVT) as the standard of care for acute ischemic stroke due to large vessel occlusion 1–3. As EVT case volumes at qualified centers increase due to expanding treatment indications and improved systems of care, the probability of multiple patients with large vessel occlusion presenting concurrently for time sensitive treatment is also expected to rise 2 4–11. New strategies are needed to ensure optimal care for these patients while maintaining sensitivity to the ever increasing demand on neurointerventionalists 12 13…”