on behalf of the catalan stroke code and reperfusion consortium (cat-scr) Ischemic Stroke To cite: carrera D, gorchs M, Querol M, et al. J NeuroIntervent Surg epub ahead of print: [please include Day Month Year].AbSTrACT background and purpose Our aim was to revalidate the race scale, a prehospital tool that aims to identify patients with large vessel occlusion (lVO), after its region-wide implementation in catalonia, and to analyze geographical differences in access to endovascular treatment (eVT). Methods We used data from the prospective cicaT registry (stroke code catalan registry) that includes all stroke code activations. The race score evaluated by emergency medical services, time metrics, final diagnosis, presence of lVO, and type of revascularization treatment were registered. sensitivity, specificity, and area under the curve (aUc) for the race cut-off value ≥5 for identification of both lVO and eligibility for eVT were calculated. We compared the rate of eVT and time to eVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (csc). results The race scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the national institute of health stroke scale evaluated at hospital (r=0.74, P<0.001). a race score ≥5 detected lVO with a sensitivity 0.79 and specificity 0.62 (aUc 0.76). Patients with race ≥5 harbored a lVO and received eVT more frequently than race <5 patients (lVO 35% vs 6%; eVT 20% vs 6%; all P<0.001). Direct admission at a csc was independently associated with higher odds of receiving eVT compared with admission at a referral center (Or 2.40; 95% ci 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter. Conclusions This large validation study confirms race accuracy to identify stroke patients eligible for eVT, and provides evidence of geographical imbalances in the access to eVT to the detriment of patients located in remote areas. MeThodS Study setting

Five recent randomized controlled trials provided clear evidence that endovascular thrombectomy (EVT) improves outcomes after acute ischemic stroke caused by large vessel occlusions (LVOs), [1][2][3][4][5] and current guidelines recommend EVT in addition to intravenous thrombolysis (IVT) within 4.5 hours among patients with anterior circulation strokes and LVO. 6,7 Patients eligible for IVT should receive it without delay even if EVT is being considered, but the particular benefit of IVT is not yet well established. Moreover, in the real world, a significant proportion of acute ischemic stroke patients receive IVT at local stroke centers where EVT is not available. Such centers apply a drip and ship protocol when an EVT candidate is identified, with the necessary subsequent transfer causing a delayed puncture. In this context, building up evidence of the specific role of IVT when added to EVT among LVO patients is necessary to reorganize stroke systems of care accordingly. We compared direct EVT (dEVT) against combined IVT+EVT in patients with anterior circulation strokes caused by LVO. MethodsWe used data included in the SONIIA registry (Sistema Online d'Informació de l'Ictus Agut), a government-mandated, populationbased, externally audited, prospective database that includes all acute ischemic stroke patients treated with reperfusion therapies in the region Background and Purpose-Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. Methods-Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. Results-We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). of Catalonia from January 2011. Further details of this registry have been published elsewhere. 8 Briefly, the database includes relevant baseline information (prestroke medical history, medications and functional status, time of stroke onset and hospital arrival, severity, time of neuro/ vascular imaging, IVT and groin puncture time, and complications) and the neurological situation at 24 to 36 hours post-treatment, including symptomatic bleedings. Outcome variables at 3 months are good outcome (modif...

This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

We aim to determine population-based EVT rate, treatment delay, and clinical outcomes by geographical areas in Catalonia, Spain. Methods Study SettingThe region of Catalonia includes a total population of 7.5 million inhabitants and an area of 32 000 km 2 . The Catalan Stroke Program was established in 2006, a Stroke Code system to cover the entire territory of Catalonia, offering acute stroke care in 9 Primary Background and Purpose-Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model. Methods-We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups. Results-Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C.

<b><i>Background:</i></b> The evolution of the symptomatic intracranial occlusion during transfers from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs) for endovascular treatment (EVT) is not widely known. Our aim was to identify factors related to partial or complete recanalization (REC) at CSC arrival in patients with a documented large vessel occlusion (LVO) in PSC transferred for EVT evaluation to better define the workflow at CSC of this group of patients. <b><i>Methods:</i></b> We conducted an observational, multicenter study from a prospective, government-mandated, population-based registry of stroke patients with documented LVO at PSC transferred to CSC for EVT from January 2017 to June 2019. The primary end point was defined as partial or complete REC that precluded EVT at CSC arrival (REC). We evaluated the association between baseline, treatment variables and time intervals with the presence of REC. <b><i>Results:</i></b> From 589 patients, the rate of REC at CSC was 10.5% in all LVO patients transferred from PSC to CSC for EVT evaluation. On univariate analysis, lower PSC-NIHSS (median 12vs.16, <i>p</i> = 0.001), tPA treatment at PSC (13.7 vs. 5.0%; <i>p</i> = 0.001), presence of M2 occlusion on PSC (16.8 vs. 9%; <i>p</i> = 0.023), and clinical improvement at CSC arrival (21.7 vs. 9.6% <i>p</i> = 0.001) were associated with REC at CSC. On multivariate analysis, clinical improvement at CSC arrival (<i>p</i> &#x3c; 0.001, OR: 5.96 95% CI: 2.5–13.9) and PSC tPA treatment predicted REC (<i>p</i> = 0.003, OR: 4.65, 95% CI: 1.73–12.4). <b><i>Conclusion:</i></b> REC at CSC arrival occurs exceptionally in patients with a documented LVO on PSC. Repeating a second vascular study before EVT would not be necessary in most patients. Despite its modest effect, tPA treatment at PSC was an independent predictor of REC.