Access to Endovascular Treatment in Remote Areas

Abstract

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.

Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion

“…False negative patients were principally patients with LVO with mild or moderate symptoms severity. Compared with true positive patients, false negative patients had lower stroke severity (median RACE 3 [2][3][4] and median NIHSS 13 [8][9][10][11][12][13][14][15][16][17][18] vs. RACE 7 [6][7][8] and NIHSS 19 [16][17][18][19][20][21][22], P<0.001 for both comparisons) and more frequently scored NIHSS <6 (15% vs 2%, P<0.001). False negatives showed more frequently tandem occlusion (33% vs 16%), less frequently ACM-M1 (52% vs 61%) and TICA (12% vs 19%) occlusions than true positives, with no differences on basilar occlusion (2.1% vs 4.2%).…”

“…1 Because of the limited availability of EVT and its time-dependent efficacy, there is a critical need to develop strategies to identify at a prehospital level those patients who are candidates for EVT. 2 In the past few years, several prehospital scales have been proposed. The optimal clinical tool should strike the right balance between sensitivity and specificity, that is, its ability to capture as many LVO patients as possible to avoid an excess of unnecessary transfers to comprehensive stroke centers (CSC).…”

Innovation in Systems of Care in Acute Phase of Ischemic Stroke. The Experience of the Catalan Stroke Programme

“…According to the Stroke Code protocol, patients with a suspected acute stroke are transferred to the closest SC or TSC in order to prioritize urgent expert evaluation and rapid IVT if indicated. This strategy is extremely effective and safe, increasing IVT treatment and reducing the time from symptom onset to IVT initiation; however, this decentralized model is associated with delayed EVT initiation and lower rates of EVT, compared to areas where patients are directly transferred to a CSC ( 26 ).…”

“…Now that reperfusion therapies, specifically interventionism, have been shown to be beneficial in AIS patients with proximal LVO, stroke systems of care should be reorganized to provide acute treatment, including mechanical thrombectomy, in a timely and equitable manner. Recent studies, including one performed in Catalonia, have demonstrated that access to EVT from remote areas is limited in high-income countries ( 26 ) and geographic disparities in IVT use are increasing, showing a rural-urban inequality trend ( 27 ). In a rural area of North Carolina, researchers showed that re-organization of the stroke system of care (in that case, to pursuit official certification of the hospital) allowed patients to receive evaluation and treatment in a timely and efficient manner close to home ( 28 ).…”

Promoting Neurovascular Recovery in Aged Mice after Ischemic Stroke - Prophylactic Effect of Omega-3 Polyunsaturated Fatty Acids

“…Other than endovascular clot removal, which is hampered by surgical site accessibility [ 6 ], no effective therapeutic strategy is available for the treatment of aged individuals. Previous studies have demonstrated that the young adult brain possesses the ability to initiate repair processes itself following ischemic stroke [ 7 - 10 ].…”