Futile Interhospital Transfer for Endovascular Treatment in Acute Ischemic Stroke

Abstract

However, the complexity of this technique justifies the development of collaborative stroke center networks with interhospital transfers of eligible patients. 6 To date, these stroke care networks have been implemented in regional settings, connecting a comprehensive stroke center (CSC) with primary stroke centers and general hospitals. 6 This approach has been designed principally to improve the rates of IVT in IS, but it has also played an important role in patients eligible Background and Purpose-The complexity of endovascular revascularization treatment (ERT) in acute ischemic stroke and the small number of patients eligible for treatment justify the development of stroke center networks with interhospital patient transfers. However, this approach might result in futile transfers (ie, the transfer of patients who ultimately do not undergo ERT). Our aim was to analyze the frequency of these futile transfers and the reasons for discarding ERT and to identify the possible associated factors. Methods-We analyzed an observational prospective ERT registry from a stroke collaboration ERT network consisting of 3 hospitals. There were interhospital transfers from the first attending hospital to the on-call ERT center for the patients for whom this therapy was indicated, either primarily or after intravenous thrombolysis (drip and shift). Results-The ERT protocol was activated for 199 patients, 129 of whom underwent ERT (64.8%). A total of 120 (60.3%) patients required a hospital transfer, 50 of whom (41%) ultimately did not undergo ERT. There were no differences in their baseline characteristics, the times from stroke onset, or in the delays in interhospital transfers between the transferred patients who were treated and those who were not treated. The main reasons for rejecting ERT after the interhospital transfer were clinical improvement/arterial recanalization (48%) and neuroimaging criteria (32%). Conclusions-Forty-one percent of the ERT transfers were futile, but none of the baseline patient characteristics predicted this result. Futility could be reduced if repetition of unnecessary diagnostic tests was avoided.

ASPECTS decay during inter-facility transfer in patients with large vessel occlusion strokes

“…Our analysis showed that one in three patients showed ASPECTS decay towards an unfavorable score (<6), and there were no reliable and simple criteria to identify which patients would show such evolution, except for NIHSS severity. Similar findings were reported in the study of the Madrid Stroke Network, in which analysis of the transfer of patients who ultimately do not undergo endovascular interventions was performed 7. The study reported no difference in baseline characteristics between the patients who were treated or excluded from IA interventions, and unfavorable neuroimaging criteria (defined as ASPECTS <7) were the reason for such ‘futile’ transport in 32% of those patients who ultimately did not undergo endovascular revascularization.…”

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

“…This rate is higher than in other series,18 20–22(24.2% to 41%), but the distance and consequently the transfer time were longer in our situation (94 min vs 56 min in the study by Fuentes et al) 20. Previous studies showed that inter-hospital transfer delays are a major cause of FT 18 23.…”

Prehospital care delivery and triage of stroke with emergent large vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery

“…The treatment effect of mechanical embolectomy for patients with ELVO is substantial, with one of three to four patients benefiting in several large trials 2–4. In a Spanish study of futile transfer between facilities for endovascular therapy with a median transfer time of 60 min, 32% of the patients excluded from endovascular treatment were found to be ineligible at the receiving facility based upon the imaging progression of stroke 89. EMS transport protocols for patients with ELVO, based on best evidence, must ensure equitable population access to this effective therapy.…”