Futile inter-hospital transfer for mechanical thrombectomy in a semi-rural context: analysis of a 6-year prospective registry

Abstract

Background and purposeInter-hospital transfer for mechanical thrombectomy (MT) might result in the transfer of patients who finally will not undergo MT (ie, futile transfers [FT]). This study evaluated FT frequency in a primary stroke center (PSC) in a semi-rural area and at 156 km from the comprehensive stroke center (CSC).MethodologyRetrospective analysis of data collected in a 6-year prospective registry concerning patients admitted to our PSC within 4.5 hours of acute ischemic stroke (AIS) symptom onset, with MR angiography indicating the presence of large vessel occlusion (LVO) without large cerebral infarction (DWI-ASPECT ≥5), and selected for transfer to the CSC to undergo MT. Futile transfer rate and reasons were determined, and the relevant time measures recorded.ResultsAmong the 529 patients screened for MT, 278 (52.6%) were transferred to the CSC. Futile transfer rate was 45% (n=125/278) and the three main reasons for FT were: clinical improvement and reperfusion on MRI on arrival at the CSC (58.4% of FT); clinical worsening and/or infarct growth (16.8%); and longer than expected inter-hospital transfer time (11.2%). Predictive factors of FT due to clinical improvement/reperfusion on MRI could not be identified. Baseline higher NIHSS (21 vs 17; P=0.01) and lower DWI-ASPECT score (5 vs 7; P=0.001) were associated with FT due to clinical worsening/infarct growth on MRI.ConclusionsIn our setting, 45% of transfers for MT were futile. None of the baseline factors could predict FT, but the initial symptom severity was associated with FT caused byclinical worsening/infarct growth.

Optimizing Patient Selection for Interhospital Transfer and Endovascular Therapy in Acute Ischemic Stroke: Real-World Data From a Supraregional, Hub-and-Spoke Neurovascular Network in Germany

“…Similar rates in CTA performance within 15 min after NCT (at the PSC) were observed between groups. Significantly higher ASPECT scores (at the CSC) were noted in the EVT compared to the No-EVT group [median (IQR): 10 (9-10) vs. 7 (5)(6)(7)(8)(9)(10), p = 0.001]. The rates of CTP mismatch were significantly higher in the EVT compared to the No-EVT group (p < 0.001).…”

“…Currently, the operational workflow in most supraregional neurovascular networks (4, 5) entails acute AIS management, including administration of intravenous thrombolysis, at primary stroke centers (PSCs) followed by emergency interhospital patient transfer to comprehensive stroke centers (CSCs) when EVT is required. Although a growing number of studies have dealt with reasons for unsuccessful EVT in patients transferred from PSCs to CSCs (i.e., the "drip-and-ship" strategy) (6) compared to patients directly transferred to the nearest CSC (i.e., the "mothership" strategy) (7,8), little is known regarding factors that determine the decision-making processes for patient-transfer within neurovascular networks. As current EVT registries, including the German Stroke Registry Endovascular Treatment (GSR-ET) (9, 10), only capture data of transferred patients with intention-to-treat with EVT at the CSCs, realworld evidence on patient selection for interhospital transfer are lacking.…”

Delayed Thrombectomy Center Arrival is Associated with Decreased Treatment Probability

“…Finally, we found that 41% of the patients received EVT, which was lower than prior reports showing a treatment rate of 55%-65%. 5,15 Given the later part of our study period overlapped with guideline changes following landmark trials showing the benefits of EVT up to 24 hours, our findings may be a reflection of lower thresholds for accepting patients with LVO in transfer. 20…”

“…This is comparable with a recent study from France that found 73 out of 278 (26%) acute stroke patients with LVO had clinical improvement or arterial recanalization after transfer and thus did not receive endovascular therapy. 15 However, their study period predated the landmark trials demonstrating EVT benefits up to 24 hours and they only included patients presenting within 4.5 hours of stroke onset. They found that patients who were not treated with EVT due to clinical improvement or recanalization had better outcomes at 3 months comparing to those not treated due to other reasons (74% vs. 17% mRS 0-2).…”

Early Lessons From World War COVID Reinventing Our Stroke Systems of Care

“…15 Another large series in France identified a 45% rate of transfer without resulting in EST. 16 Looking at these so-called futile transfers through the lens of our current reality in the setting of COVID-19, the need to limit or eliminate these occurrences has become exceedingly clear. These are patients who should stay and receive care at local hospitals, and to do so, we must build our systems of care to bring expertise in Vascular Neurology and NeuroImaging to those patients, as discussed below.…”