Question: Is early neurological deterioration of ischemic origin (END i ) predictable in minor strokes with large vessel occlusion (LVO) treated with intravenous thrombolysis (IVT)?Findings: In a multicentric retrospective cohort of minor stroke patients (NIHSS≤5) with LVO intended for IVT alone (n=729), an easily applicable score based on occlusion site and thrombus length -two independent predictors of END i -showed good discriminative power for END i risk prediction, and was successfully validated in an independent cohort (n=347).Meaning: END i can be reliably predicted in IVT-treated minor strokes with LVO, which may help to select the best candidates for direct transfer for additional thrombectomy.

Background and purposeInter-hospital transfer for mechanical thrombectomy (MT) might result in the transfer of patients who finally will not undergo MT (ie, futile transfers [FT]). This study evaluated FT frequency in a primary stroke center (PSC) in a semi-rural area and at 156 km from the comprehensive stroke center (CSC).MethodologyRetrospective analysis of data collected in a 6-year prospective registry concerning patients admitted to our PSC within 4.5 hours of acute ischemic stroke (AIS) symptom onset, with MR angiography indicating the presence of large vessel occlusion (LVO) without large cerebral infarction (DWI-ASPECT ≥5), and selected for transfer to the CSC to undergo MT. Futile transfer rate and reasons were determined, and the relevant time measures recorded.ResultsAmong the 529 patients screened for MT, 278 (52.6%) were transferred to the CSC. Futile transfer rate was 45% (n=125/278) and the three main reasons for FT were: clinical improvement and reperfusion on MRI on arrival at the CSC (58.4% of FT); clinical worsening and/or infarct growth (16.8%); and longer than expected inter-hospital transfer time (11.2%). Predictive factors of FT due to clinical improvement/reperfusion on MRI could not be identified. Baseline higher NIHSS (21 vs 17; P=0.01) and lower DWI-ASPECT score (5 vs 7; P=0.001) were associated with FT due to clinical worsening/infarct growth on MRI.ConclusionsIn our setting, 45% of transfers for MT were futile. None of the baseline factors could predict FT, but the initial symptom severity was associated with FT caused byclinical worsening/infarct growth.

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Background: No comprehensive study exists about mechanical thrombectomy accessibility for patients admitted to a primary stroke center without onsite interventional neuroradiology service.Aims: To evaluate mechanical thrombectomy accessibility within 6 h after transfer from a primary stroke center to a distant (156 km apart; 1.5 h by car) comprehensive stroke center.Methods: Analysis of data collected in a three-year prospective registry on patients admitted to a primary stroke center within 4.5 h after symptom onset and selected for transfer to a comprehensive stroke center for mechanical thrombectomy. Eligible patients had confirmed proximal arterial occlusion and no large cerebral infarction on MRI images (DWI-ASPECTS 5). The rate of transfer, transfer without mechanical thrombectomy, mechanical thrombectomy, reperfusion (TICI score 2b-3), and the main relevant time measures were determined.Results: Among the 385 patients selected for intravenous thrombolysis and/or potential mechanical thrombectomy, 211 were considered as transferrable for mechanical thrombectomy. The rate of transfer was 56.4% (n ¼ 119/211), transfer without mechanical thrombectomy 56.3% (n ¼ 67/119), mechanical thrombectomy 24.6% (n ¼ 52/211), and reperfusion by MT (TICI score 2b/3) 18% (n ¼ 38/211). The relevant median times (interquartile range) were: 130 min (62) for intravenous thrombolysis start to comprehensive stroke center door, 95 minutes (39) for primary stroke center doorout to comprehensive stroke center door-in, 191 min (44) for intravenous thrombolysis start to mechanical thrombectomy puncture, 354 min (107) for symptom onset to mechanical thrombectomy puncture and 417 min (124) for symptom onset to recanalization.Conclusions: Our study suggests that transfer to a distant comprehensive stroke center is associated with reduced access to early mechanical thrombectomy in patients with acute ischemic stroke and large artery occlusion. These results could be translated to other high volume distant primary stroke center.

Objective: The purpose of this study was to demonstrate that the median door-to-needle (DTN) time for intravenous tissue plasminogen activator (tPA) treatment can be reduced to 45 min in a primary stroke centre with MRI-based screening for acute ischaemic stroke (AIS). Methods: From February 2015 to February 2017, the stroke unit of Perpignan general hospital, France, implemented a quality-improvement (QI) process. During this period, patients who received tPA within 4.5 h after AIS onset were included in the QI cohort. Their clinical characteristics and timing metrics were compared each semester and also with those of 135 consecutive patients with AIS treated by tPA during the 1-year pre-QI period (pre-QI cohort). Results: In the QI cohort, 274 patients (92.5%) underwent MRI screening. While the demographic and baseline characteristics were not significantly different between cohorts, the median DTN time was significantly lower in the QI than in the pre-QI cohort (52 vs. 84 min; p < 0.00001). Within the QI cohort, the median DTN time for each semester decreased from 65 to 44 min (p < 0.00001) and the proportion of treated patients with a DTN time ≤45 min increased from 25 to 58.9% (p < 0.0001). Overall, DTN time improvement was associated with a better outcome at 3 months (patients with a modified Rankin Scale score between 0 and 2: 61.8% in the QI vs. 39.3% in the pre-QI cohort; p < 0.0001). Conclusions: A QI process can reduce the DTN within 45 min with MRI as a screening tool.