Workflow and factors associated with delay in the delivery of intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial

Venema, Esmée; Boodt, Nikki; Berkhemer, Olvert A.; Rood, P.P.M.; Zwam, Wim H van; Oostenbrugge, Robert J. van; Lugt, Aad van der; Roos, Yvo B.W.E.M.; Majoie, Charles B. L. M.; Lingsma, Hester F.; Dippel, Diederik W.J.

doi:10.1136/neurintsurg-2017-013198

Cited by 28 publications

(20 citation statements)

References 33 publications

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“…This analysis fails to account for the many patients that were no longer candidates for EVT by the time they arrived at the endovascular-capable center due to interval stroke progression. Similar results were obtained from analysis of the MR CLEAN trial and the STRATIS registry [4, 5]. Indeed, a small non-randomized observational study demonstrated that one out of three patients with LVO with initial favorable imaging profile became ineligible for endovascular thrombectomy during inter-hospital transfer based on ASPECTS criteria [6].…”

Section: Prehospital Triagesupporting

confidence: 58%

An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

et al. 2018

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Section: Prehospital Triagesupporting

confidence: 58%

An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

et al. 2018

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“…These transfers may delay time to treatment and are associated with worse outcomes than with direct presentation to CSCs 10–12. Similar to protocols for trauma and ST segment elevation myocardial infarction, direct field triage by EMS to a more distant CSC based on clinical suspicion of ELVO has been proposed as a solution for reducing time to EVT, although potentially at the expense of delaying time to intravenous thrombolysis 13.…”

Section: Introductionmentioning

confidence: 99%

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

Jayaraman

Hemendinger

Baird

et al. 2019

J NeuroIntervent Surg

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BackgroundEndovascular therapy (EVT) for stroke improves outcomes but is time sensitive.ObjectiveTo compare times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC).MethodsDuring the study, a portion of our region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. We compared times to treatment and clinical outcomes between those two groups. Additionally, we performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC.ResultsOver 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC; 144 were taken to the closest PSC and 88 to the more distant CSC. The median additional transport time to the CSC was 7 min. Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; p<0.001 for both). Among patients who were independent before the stroke, the OR for less disability in the direct group was 1.47 (95% CI 1.13 to 1.93, p=0.003), and 2.06 (95% CI 1.10 to 3.89, p=0.01) for the matched pairs.ConclusionsIn a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.

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“…36,37 Another explanation might be that not yet all patients who might benefit from EVT are being recognized in time prehospital and in hospital, even though CTA has been advised as standard diagnostic procedure for all patients with acute ischemic stroke. 38 Also, in current clinical practice, most suspected stroke patients are first transported to the nearest hospital for immediate treatment with IVT, which can lead to delay of the start of EVT and worse outcomes because of additional time needed for transfer to an endovascular capable center. 39 Acute stroke care in the Netherlands is organized as follows.…”

Section: Discussionmentioning

confidence: 99%

Path From Clinical Research to Implementation

Wiegers

Compagne

Janssen

et al. 2020

Stroke

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Before 2015, endovascular treatment (EVT) for acute ischemic stroke was considered a promising treatment option. Based on limited evidence, it was performed in several dedicated stroke centers worldwide on selected patients. Since 2015, EVT for patients with intracranial large vessel occlusion has quickly been implemented as standard treatment in many countries worldwide, supported by the revised international guidelines based on solid evidence from multiple clinical trials. We describe the development in use of EVT in the Netherlands before, during, and after the pivotal EVT trials. We used data from all patients who were treated with EVT in the Netherlands from January 2002 until December 2018. We undertook a time-series analysis to examine trends in the use of EVT using Poisson regression analysis. Incidence rate ratios per year with 95% CIs were obtained to demonstrate the impact and implementation after the publication of the EVT trial results. We made regional observation plots, adjusted for stroke incidence, to assess the availability and use of the treatment in the country. In the buildup to the MR CLEAN (Multicenter Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands), a slow increase of EVT patients was observed, with 0.2% of all ischemic stroke patients receiving EVT. Before the trial results were formally announced, a statistically significant increase in EVT-treated patients per year was observed (incidence rate ratio, 1.72 [95% CI, 1.46–2.04]), and after the trial publication, an immediate steep increase was seen, followed by a more gradual increase (incidence rate ratio, 2.14 [95% CI, 1.77–2.59]). In 2018, the percentage of ischemic stroke patients receiving EVT increased to 5.8%. A well-developed infrastructure, a pragmatic approach toward the use of EVT in clinical practice, in combination with a strict adherence by the regulatory authorities to national evidence-based guidelines has led to successful implementation of EVT in the Netherlands. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT in all regions of the country.

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Workflow and factors associated with delay in the delivery of intra-arterial treatment for acute ischemic stroke in the MR CLEAN trial

Abstract: Inter-hospital transfer is an important cause of delay in the delivery of IAT and every effort should be made to avoid transfers and reduce transfer-related delay. Furthermore, in-hospital workflow should be optimized to improve functional outcome after IAT.

Cited by 28 publications

References 33 publications

An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke

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

Path From Clinical Research to Implementation

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