Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy

Abstract

Background and Purpose-In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times. Methods-We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV). Results-A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P=0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P=0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P=0.001). Conclusions-DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial.

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

“…Additionally, we feel that our matched-pairs design with mixed modeling of pre-stroke and 90-day mRS score, matching according to time to CSC and NIHSS score, provides a strong alterative to randomization for these observational data. We have substantially improved EMS knowledge of our severity-based field triage protocol, optimized PSC and CSC workflow through an extensive quality improvement process, standardized imaging and procedural technique, avoiding general anesthesia, and transporting most transfer patients directly to the angiography suite without repeat imaging 18 20 28 34 35. Our results should be interpreted with caution in regions where the distribution and workflow metrics of stroke centers are not similar.…”

Diagnosing Early Ischemic Changes with the Latest-Generation Flat Detector CT: A Comparative Study with Multidetector CT

“…Innovative approaches to reduce door-to-groin times have been proposed recently for patients with LVO. 5,6,9,11 These approaches include the direct referral of MT-eligible patients to the angiography suite with a variation of imaging or no imaging proposed by the various authors. We have recently published an innovative one-stop-management protocol, which includes both nonconstrast imaging and multiphase CTA (acquired in the angiography suite).…”

“…4 A recent retrospective analysis comparing patients with direct referral to the angiography suite for MT and patients with prior admission to the emergency department showed significantly reduced symptomto-treatment times and demonstrated the feasibility and safety of this approach. 5 Rather than omitting the emergency department, another approach to direct angiography suite referral is to skip the multidetector CT (MDCT), performing emergency stroke imaging in the angiography suite with flat detector CT (FDCT) and multiphase flat detector CTA followed by MT without delay. This previously reported approach 6,7 explicitly addresses the delay from MDCT imaging to angiography suite referral, which has been identified as a crucial factor concerning in-hospital delays for the treatment of MT-eligible patients.…”

Pre-hospital detection of acute ischemic stroke secondary to emergent large vessel occlusion: lessons learned from electrocardiogram and acute myocardial infarction

“…However, with the lack of a technology analogous to PHECG and the lack of reliable clinical tools to detect ELVO in the pre-hospital setting, the achievable results of nECC bypass based on clinical symptoms alone are inherently limited. In addition to nECC bypass, others have found success meeting guideline-recommended treatment time goals by streamlining ED team workflow and angiography suite activation 32. Therefore, based on experience gathered during PHECG testing and current research efforts in ELVO, future device testing should focus efforts on: 1) time delays to reperfusion therapy, including AMS transport times, inter-hospital transfer delays, ED team workflow, access to CTA imaging, and angiography suite activation efficiency; 2) adherence to guideline-recommended treatment time objectives39 and 3) integration of ELVO devices into nECC bypass protocols currently under development 34–37 40 41…”