Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

Abstract

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

Immune Cells Invade the Collateral Circulation during Human Stroke: Prospective Replication and Extension

“…Pre-interventional infarct extent at stroke center presentation and early follow-up infarct extent at 24-48 h following recanalization were measured through the Alberta Stroke Program Early CT Score (ASPECTS; CT: Somatom Definition AS; Siemens Healthineers, Erlangen, Germany) [39]. Post-processing algorithms (syngo iFLOW software; Siemens Healthineers, Erlangen, Germany) were applied for parametric color coding of digital subtraction angiography (DSA) series and for the quantification of collateralization during occlusive conditions.…”

Blockade of Platelet Glycoprotein Ibα Augments Neuroprotection in Orai2-Deficient Mice during Middle Cerebral Artery Occlusion

“…It is well established that if, under LVO, timely recanalization cannot be achieved, infarcts rapidly grow and that the velocity of penumbral tissue loss depends on the degree of collateral blood flow [ 1 ]. To date, typical patients eligible for MT have to be transferred frequently from remote hospitals to primary stroke centers, causing significant delays which lead to clinically highly relevant early infarct growth, which in turn is closely associated with loss of favorable outcomes [ 8 ]. This current core clinical problem makes urgent experimental and clinical studies aiming to prevent infarct growth before recanalization and ischemia–reperfusion injury thereafter.…”

Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment

“…One of the main goals of pre-hospital EVT triage, besides recognizing AIS, is to direct patients who are likely to be EVT candidates to an EVT and IV thrombolysis-capable hospital (comprehensive stroke center, CSC) to minimize time to EVT and prevent further infarct progression. 31 At the same time, patients who are unlikely to be EVT candidates should be directed to the closest PSC, to minimize time to IV thrombolysis (ie, onset to needle time). With regard to IV thrombolysis at the CSC in EVT candidates, several recently published randomized controlled trials [32][33][34][35][36] have investigated the question whether IV thrombolysis could be forgone in EVT candidates presenting directly to the CSC; overall, the current evidence from these trials does not support withholding IV thrombolysis in these patients, although there are some subgroups in which the added benefit of IV thrombolysis should be further investigated.…”

“…One of the main goals of pre-hospital EVT triage, besides recognizing AIS, is to direct patients who are likely to be EVT candidates to an EVT and IV thrombolysis-capable hospital (comprehensive stroke center, CSC) to minimize time to EVT and prevent further infarct progression 31. At the same time, patients who are unlikely to be EVT candidates should be directed to the closest PSC, to minimize time to IV thrombolysis (ie, onset to needle time).…”