Should Primary Stroke Centers Perform Advanced Imaging?

Hill, Michael D.; Warach, Steven; Rostanski, Sara

doi:10.1161/strokeaha.121.033528

Cited by 10 publications

(11 citation statements)

References 47 publications

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“…Therefore, exploring the role of vascular imaging teleconsultation27 and new technologies like automatized vascular occlusion detection software28 for centers lacking personal and/or logistic capabilities to perform vascular imaging should be evaluated. From a general perspective, the findings observed in the present study could provide support to explore the use of advanced imaging in a LSC—a controversial topic, currently subject to debate 29…”

Section: Discussionsupporting

confidence: 59%

Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis

Flores

García‐Tornel

Seró

et al. 2023

J NeuroIntervent Surg

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BackgroundThe influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI− at LSC arrival on variables related to workflows using data from the RACECAT Trial.ObjectiveTo compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition.MethodsWe included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients.ResultsAmong 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69–96) vs VI− 76 (IQR 59–98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26–53) vs VI− 54 (IQR 40–70), P<0.001).ConclusionAmong patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.

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Section: Discussionsupporting

confidence: 59%

Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis

Flores

García‐Tornel

Seró

et al. 2023

J NeuroIntervent Surg

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“…Focusing on patients with high HIR may be warranted, as a significant therapeutic benefit seems less likely in patients with low HIR. Second, these data could also inform the primary center's decision regarding whether a transfer is advisable, as well as the comprehensive centers' assessment regarding whether repeat imaging is warranted prior to initiating the thrombectomy procedure 29,30 . Considering the mild IG in patients with low HIR, repeating imaging at the comprehensive center for a clinically stable patient during transfer is unlikely to alter the decision to proceed with thrombectomy.…”

Section: Discussionmentioning

confidence: 99%

“…Second, these data could also inform the primary center's decision regarding whether a transfer is advisable, as well as the comprehensive centers' assessment regarding whether repeat imaging is warranted prior to initiating the thrombectomy procedure. 29,30 Considering the mild IG in patients with low HIR, repeating imaging at the comprehensive center for a clinically stable patient during transfer is unlikely to alter the decision to proceed with thrombectomy. In contrast, the substantial IG in patients with high HIR resulted in the lack of significant mismatch in one third of patients at the comprehensive center, a situation where thrombectomy has been considered unfavorable.…”

Section: Discussionmentioning

confidence: 99%

Determinants of Infarct Core Growth During Inter‐hospital Transfer for Thrombectomy

Seners

Scheldeman

Christensen

et al. 2023

Annals of Neurology

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Objective: Patients with acute ischemic stroke harboring a large vessel occlusion who present to primary stroke centers often require inter-hospital transfer for thrombectomy. We aimed to determine clinical and imaging factors independently associated with fast infarct growth (IG) during inter-hospital transfer. Methods: We retrospectively analyzed data from acute stroke patients with a large vessel occlusion transferred for thrombectomy from a primary stroke center to one of three French comprehensive stroke centers, with an MRI obtained at both the primary and comprehensive center before thrombectomy. Inter-hospital IG rate was defined as the difference in infarct volumes on diffusion-weighted imaging between the primary and comprehensive center, divided by the delay between the two MRI scans. The primary outcome was identification of fast progressors, defined as IG rate ≥5 mL/hour. The hypoperfusion intensity ratio (HIR), a surrogate marker of collateral blood flow, was automatically measured on perfusion imaging. Results: A total of 233 patients were included, of whom 27% patients were fast progressors. The percentage of fast progressors was 3% among patients with HIR < 0.40 and 71% among those with HIR ≥ 0.40. In multivariable analysis, fast progression was independently associated with HIR, intracranial carotid artery occlusion, and exclusively deep infarct location at the primary center (C-statistic = 0.95; 95% confidence interval [CI], 0.93-0.98). IG rate was independently associated with good functional outcome (adjusted OR = 0.91; 95% CI, 0.83-0.99; P = 0.037). Interpretation: Our findings show that a HIR > 0.40 is a powerful indicator of fast inter-hospital IG. These results have implication for neuroprotection trial design, as well as informing triage decisions at primary stroke centers.

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“…Moreover, predicting IG may also be useful for patient triage in primary stroke centers, to help determine whether an interhospital transfer to an endovascular capable center is advisable, because some patients with prestroke disability and significant IG may arrive at the comprehensive center with an extensive infarct and be deemed ineligible for thrombectomy. [4][5][6][7] Our study has several strengths. First, the multicenter design provided a large sample size, allowing us to reliably assess the relationship between baseline variables, including HIR and EIGR in both CT-assessed and MRI-assessed patients.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, predicting IG may also be useful for patient triage in primary stroke centers. 4,5 Several studies have reported that leptomeningeal collateral flow, either assessed on CT angiography or on perfusion imaging using the hypoperfusion intensity ratio (HIR), is the main factor associated with fast IG. [6][7][8][9][10][11][12][13][14][15] The HIR reflects the percentage of the perfusion lesion that has severely delayed contrast arrival times and correlates with the quality of the collateral circulation determined by angiography.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated With Fast Early Infarct Growth in Patients With Acute Ischemic Stroke With a Large Vessel Occlusion

Seners,

Yuen,

Olivot

et al. 2023

Neurology

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Background and objectives:The optimal methods for predicting early infarct growth rate (EIGR) in acute ischemic stroke with a large vessel occlusion (LVO) have not been established. We aimed to study the factors associated with EIGR, with a focus on the collateral circulation as assessed by the Hypoperfusion Intensity Ratio (HIR) on perfusion imaging, and determine whether the associations found are consistent across imaging modalities.Methods:Retrospective multicenter international study including anterior circulation LVO-related acute stroke patients with witnessed stroke onset and baseline perfusion imaging (MRI or CT) performed within 24hrs from symptom onset. To avoid selection bias, patients were selected from (1) the prospective registries of four comprehensive stroke centers with systematic use of perfusion imaging and including both thrombectomy-treated and untreated patients, and (2) one prospective thrombectomy study where perfusion imaging was acquired per protocol but treatment decisions were made blinded to the results. EIGR was defined as infarct volume on baseline imaging divided by onset-to-imaging time, and fast progressors as EIGR ≥10mL/hr. The HIR, defined as the proportion of Tmax>6s with Tmax>10s volume, was measured on perfusion imaging using RAPID software. The factors independently associated with fast progression were studied using multivariable logistic regression models, with separate analyses for CT- and MRI-assessed patients.Results:Overall, 1127 patients were included (CT, n=471; MRI, n=656). Median age was 74 years (IQR, 62-83), 52% were male, median NIHSS was 16 (IQR, 9-21), median HIR was 0.42 (IQR, 0.26-0.58) and 415 (37%) were fast progressors. The HIR was the primary factor associated with fast progression, with very similar results across imaging modalities: the proportion of fast progressors was 4% in the first HIR quartile (i.e.excellent collaterals), ∼15% in the second, ∼50% in the third, and ∼77% in the fourth (P<0.001 for each imaging modality). Fast progression was independently associated with poor 3-month functional outcome in both the CT and MRI cohorts (P<0.001 andP=0.030, respectively).Discussion:The HIR is the primary factor associated with fast infarct progression, regardless of imaging modality. These results have implication for neuroprotection trial design, as well as informing triage decisions at primary stroke centers.

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Should Primary Stroke Centers Perform Advanced Imaging?

Cited by 10 publications

References 47 publications

Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis

Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis

Determinants of Infarct Core Growth During Inter‐hospital Transfer for Thrombectomy

Factors Associated With Fast Early Infarct Growth in Patients With Acute Ischemic Stroke With a Large Vessel Occlusion

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