How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry

Abstract

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392

Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy

“…Treatment times were in line with proposed time metrics from guidelines and with treatment time targets of trials with focus on rapid treatment work-flow ( 7 , 8 , 17 ). However, despite implementation of the EVT-call, the door-to-groin puncture time in our cohort was still longer compared to the average door-to-groin puncture time of patients transferred via a primary stroke center in the German stroke registry (median door-to-groin time: 44 min [IQR 30–67]) ( 18 ). Potential reasons for delay in our hospital are the relatively high rate of periinterventional intubation during the study period (62.1%) and repeated imaging after arrival at our center as a standardized procedure.…”

“…Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81], NIHSS score 17 [12][13][14][15][16][17][18][19][20][21][22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call).…”

“…We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (-EVT-Call) and after (+EVT-Call) implementation of the EVT-Call.Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81], NIHSS score 17 [12][13][14][15][16][17][18][19][20][21][22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call).…”

Workflow Intervals and Outcomes of Endovascular Treatment for Acute Large-Vessel Occlusion During On-Vs. Off-hours in China: The ANGEL-ACT Registry

“…Previous research has also described this phenomenon (16). Notably, in the treatment of patients requiring EVT, interhospital transfer will increase the onset-to-first door time (30)(31)(32). Therefore, when establishing the EVT process, the delay caused by referral should be recognized, special attention should be given to the impact of off-hours referrals, and effective public information campaigns should be used to make patients aware of hospitals with 24-h EVT capabilities in advance to ensure that patients can be delivered directly after stroke onset.…”

New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT

“…Our secondary aim was to determine whether the change of triage method has led to better clinical outcomes. The study by Herm et al ( 17 ) focused on analysis of the DGT within the German Stroke Registry of EVT-treated patients and its impact on functional outcome. Fifty-six percent of the patients were primarily treated in CSC and 44% of the patients were primarily treated in PSC and then transferred to CSC.…”