Transfer to High-Volume Centers Associated With Reduced Mortality After Endovascular Treatment of Acute Stroke

Rinaldo, Lorenzo; Brinjikji, Waleed; Rabinstein, Alejandro A.

doi:10.1161/strokeaha.116.016360

Cited by 89 publications

(88 citation statements)

References 18 publications

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“…Centres with high volume of ECR have a reduced rate of mortality compared to low-volume centres (9.8% compared to 19.7%) [14]. High-volume centres have also been shown to have shorter times from CT to groin puncture, better clinical outcomes and better reperfusion rates in ECR for acute ischaemic stroke due to large vessel occlusion [15].…”

Section: Introductionmentioning

confidence: 99%

Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

et al. 2018

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Background: Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a “hub-and-spoke” model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the “hub-and-spoke” model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems. Methods: We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the “hub-and-spoke” model. Good clinical outcome was defined as modified Rankin Scale 0–2 and the difference between the 2 groups was tested by logistic regression. Results: Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58–77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48–77%) achieved good clinical outcomes compared to 52% (95% CI 43–61%) in the “hub-and-spoke” group (p = 0.233). Conclusion: This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with “hub-and-spoke” service delivery.

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Section: Introductionmentioning

confidence: 99%

Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

et al. 2018

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“…If confirmed, our data suggest that in such a setting scales like the FAST-ED and RACE may be advantageous as they appeared less impervious to leukoaraiosis-related misclassification. Furthermore, LVO scales are increasingly used to render decisions regarding immediate patient transfer to EST capable hospitals when LVO is suspected, 13,21-23 including in the setting of telemedicine consultations. 24 In this setting our results may be impactful when a plain head CT is reviewed (and provide information on leukoaraiosis severity) but no CTA obtained due to lack of resources, immediate availability, or because it is undesirable to avoid repeat imaging at the EST-capable hub hospital.…”

Section: Discussionmentioning

confidence: 99%

Leukoaraiosis Attenuates Diagnostic Accuracy of Large-Vessel Occlusion Scales

Mayasi

Goddeau

Moonis

et al. 2017

AJNR Am J Neuroradiol

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Background and purpose Pre-hospital stroke scales may help identify patients likely to have large vessel occlusion (LVO) to facilitate rapid triage to thrombectomy-capable stroke centers. Scale misclassification may result in inaccurate decisions and possible harm. Pre-existing leukoaraiosis has been shown to attenuate the association between deficit type and stroke severity. We sought to determine whether leukoaraiosis affects the predictive ability of 5 commonly used LVO scales. Materials and Methods We retrospectively analyzed 274 consecutive stroke patients with available brain MRI and vessel imaging. The following LVO scales were used: 3 Item Stroke Scale (3I/SS), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), Rapid Arterial Occlusion Evaluation (RACE), Vision, Aphasia, Neglect (VAN) score, and Cincinnati Pre-hospital Stroke Severity Scale (CPSSS). For diagnostic scale accuracy, we assessed sensitivity, specificity, positive predictive value, negative predictive value, and kappa. Multivariable logistic regression was used to determine the scales' predictive ability after adjustment for leukoaraiosis and potential confounders. Results In unadjusted analyses, all scales predicted the presence of LVO (n=46; P<0.01, each); though diagnostic accuracy was attenuated among patients with moderate-to-severe leukoaraiosis. After adjustment, the FAST-ED (OR 3.2 [1.1-9.5]; P=0.033), and RACE (OR 3.7 [1.3-10.8]; P=0.015) but not 3I/SS (OR 5.4 [0.86-33.9]); P=0.073), VAN (OR 2.5 [0.8-7.2]), and CPSSS (OR 2.8 [1.0-8.0]) predicted LVO. Conclusion The diagnostic accuracy of the tested LVO scales was attenuated in the presence of moderate-to-severe leukoaraiosis. This information that may aid the design of future studies that require LVO scale screening of patients that are likely to have concomitant leukoaraiosis.

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“…The best option for the management of AIS is to have patients transferred to and treated in high volume, level 1 centers, as demonstrated by scientific evidence 15. However, in some situations, specifically due to geographical, traffic, and transportation conditions, access of patients to such centers in an acceptable time frame may not be possible.…”

Section: Purposementioning

confidence: 99%

“…It has been shown that high volume centers have a significantly lower mortality, even if the patient has to be transferred from a low volume center. Rinaldo et al found that centers performing 35 or more thrombectomy cases per year would classify as ‘high volume’ and offer the lowest mortality rate for patients 15. Similarly, the American College of Cardiology Foundation, the American Heart Association , and the Society for Cardiovascular Angiography and Interventions suggest a minimum of 36 percutaneous coronary interventions for acute myocardial infarction per year per center as a minimum requirement 17…”

Section: Level 2 Center: Standards Of Practicementioning

confidence: 99%

Standards of practice in acute ischemic stroke intervention: international recommendations

Piérot

Jayaraman

Szikora

et al. 2018

J NeuroIntervent Surg

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Transfer to High-Volume Centers Associated With Reduced Mortality After Endovascular Treatment of Acute Stroke

Abstract: We report a beneficial effect of treatment at high-volume hospitals in spite of the detrimental effects of transfer. These findings argue for the centralization of care.

Cited by 89 publications

References 18 publications

Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

Endovascular Clot Retrieval by Hub-and-Spoke Service Delivery is Feasible Compared with Direct-to-Mothership

Leukoaraiosis Attenuates Diagnostic Accuracy of Large-Vessel Occlusion Scales

Standards of practice in acute ischemic stroke intervention: international recommendations

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