Inter-hospital transfer for mechanical thrombectomy within the supraregional stroke network NEVAS

Abstract

Background Telemedicine stroke networks are mandatory to provide inter-hospital transfer for mechanical thrombectomy (MT). However, studies on patient selection in daily practice are sparse. Methods Here, we analyzed consecutive patients from 01/2014 to 12/2018 within the supraregional stroke network “Neurovascular Network of Southwest Bavaria” (NEVAS) in terms of diagnoses after consultation, inter-hospital transfer and predictors for performing MT. Degree of disability was rated by the modified Rankin Scale (mRS), good outcome was defined as mRS ≤ 2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction (mTICI) was 2b-3. Results Of 5722 telemedicine consultations, in 14.1% inter-hospital transfer was performed, mostly because of large vessel occlusion (LVO) stroke. A total of n = 350 patients with LVO were shipped via NEVAS to our center for MT. While n = 52 recanalized spontaneously, MT-treatment was performed in n = 178 patients. MT-treated patients had more severe strokes according to the median National institute of health stroke scale (NIHSS) (16 vs. 13, p < 0.001), were more often treated with intravenous thrombolysis (64.5% vs. 51.7%, p = 0.026) and arrived significantly earlier in our center (184.5 versus 228.0 min, p < 0.001). Good outcome (27.5% vs. 30.8%, p = 0.35) and mortality (32.6% versus 23.5%, p = 0.79) were comparable in MT-treated versus no-MT-treated patients. In patients with middle cerebral artery occlusion in the M1 segment or carotid artery occlusion good outcome was twice as often in the MT-group (21.8% vs. 12.8%, p = 0.184). Independent predictors for performing MT were higher NIHSS (OR 1.096), higher ASPECTS (OR 1.28), and earlier time window (OR 0.99). Conclusion Within a telemedicine network stroke care can successfully be organized as only a minority of patients has to be transferred. Our data provide clinical evidence that all MT-eligible patients should be shipped with the fastest transportation modality as possible.

Clinical outcomes of delayed mechanical thrombectomy: Descriptive analysis and development of a screening tool

“…Our findings support a recent study showing that MT is an effective treatment in the extended time frame [5] and NCCT can be safely used to select appropriate patients [11]. Furthermore, they support recent studies showing that hub-and-spoke stroke network infrastructures enable access to successful MT in patients with stroke living remotely [12,13]. In keeping with other hub-and-spoke stroke transfer studies, we found NIHSS score, ASPECTS and age to be important determinants of outcome [12,13].…”

Prediction modelling the impact of onset to treatment time on the modified Rankin Scale score at 90 days for patients with acute ischaemic stroke

“…The CVT patient group contained the most patients, displayed the highest mean age (77.5 years) and had the lowest median NIHSS score (3) across the four patient groups at hospital admission. Conversely, the lowest mean age (71.7 years) and the highest median NIHSS score (14) were found in the IVT+MT patient group.…”

“…[7][8][9][10] Modelling the impact of patient age, the National Institutes of Health Stroke Scale (NIHSS) score at hospital admission and OTTs on patient outcomes following treatment with IVT only, MT only, IVT+MT or conservative therapy (CVT), defined as treatment with neither IVT nor MT, may help guide ongoing optimisation and improvement efforts in acute stroke care management. [11][12][13][14] This study aimed to fit regression models for predicting the modified Rankin Scale score at 90 days from stroke onset (mRS-90d score) in patients with AIS, with respect to the type of acute stroke treatment: CVT, IVT only, MT only and IVT+MT.…”

Telemedicine and Digital Health Applications in Vascular Surgery

“…Finally, the management of patients with carotid stenosis and decisions regarding carotid interventions often involve a multidisciplinary team that includes neurologists/stroke physicians, vascular surgeons and interventional radiologists [ 84 ]. Although it is not systematically reported in the literature, remote multidisciplinary discussions between specialists and the use of teleradiology services with picture archiving and communication systems (PACS) using image exchange protocols (IEP) have become common practice to optimize care of patients, especially in the context of stroke management [ 84 , 85 , 86 , 87 , 88 ].…”