Leaving No Large Vessel Occlusion Stroke Behind

McTaggart, Ryan; Holodinsky, Jessalyn K.; Ospel, Johanna M.; Cheung, Andrew; Manning, Nathan; Wenderoth, Jason; Phan, Thanh G.; Beare, Richard; Lane, Kendall; Haas, Richard; Goyal, Mayank; Jayaraman, Mahesh

doi:10.1161/strokeaha.119.026735

Cited by 15 publications

(15 citation statements)

References 63 publications

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“…Notably, 161 patients were included, out of which 99 (62%) were directly admitted and 62 (39%) were transferred patients. As expected, transferred patients had a significantly longer TFSO to imaging at our institution (median [interquartile range (IQR)]: 212 [168-261] vs. 75 min [60-106], p < 0.001) and lower ASPECTS at admission imaging (median [IQR]: 8 [6][7][8][9] vs. 9 [8][9][10], p < 0.001). The observed larger median ischemic core size of transferred patients did not reach statistical significance (median [IQR]: 40 [25-82] vs. 34 ml [21-56), p = 0.07).…”

Section: Patient Characteristicssupporting

confidence: 65%

“…Imaging assessment at PSCs typically includes non-contrast computed tomography (CT), and an increasing number of publications also recommend CT angiography (CTA) with intravenous (IV) iodine contrast (7,8). Secondary imaging at CSCs often repeats the performed examinations and complements CT perfusion (CTP) analysis (8,9). This is even the case in direct-to-angiosuite approaches with pre-therapeutic imaging using flat-panel CT (10,11).…”

Section: Introductionmentioning

confidence: 99%

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CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration

et al. 2022

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ObjectivesLarge vessel occlusion (LVO) stroke patients routinely undergo interhospital transfer to endovascular thrombectomy capable centers. Imaging is often repeated with residual intravenous (IV) iodine contrast at post-transfer assessment. We determined imaging findings and the impact of residual contrast on secondary imaging. Anterior circulation LVO stroke patients were selected out of a consecutive cohort. Directly admitted patients were contrast naïve, and transferred patients had previously received IV iodine contrast for stroke assessment at the referring hospital. Two independent readers rated the visibility of residual contrast on non-contrast computed tomography (CT) after transfer and assessed the hyperdense vessel sign. Multivariate linear regression analysis was used to investigate the association of the Alberta Stroke Program Early CT score (ASPECTS) with prior contrast administration, time from symptom onset (TFSO), and CTP ischemic core volume in both directly admitted and transferred patients.ResultsWe included 161 patients, with 62 (39%) transferred and 99 (62%) directly admitted patients. Compared between these groups, transferred patients had a longer TFSO-to-imaging at our institution (median: 212 vs. 75 min, p < 0.001) and lower ASPECTS (median: 8 vs. 9, p < 0.001). Regression analysis presented an independent association of ASPECTS with prior contrast administration (β = −0.25, p = 0.004) but not with TFSO (β = −0.03, p = 0.65). Intergroup comparison between transferred and directly admitted patients pointed toward a stronger association between ASPECTS and CTP ischemic core volume in transferred patients (β = −0.39 vs. β = −0.58, p = 0.06). Detectability of the hyperdense vessel sign was substantially lower after transfer (66 vs. 10%, p < 0.001).ConclusionImaging alterations due to residual IV contrast are frequent in clinical practice and render the hyperdense vessel sign largely indetectable. Larger studies are needed to clarify the influence on the association between ASPECTS and ischemic core.

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Section: Patient Characteristicssupporting

confidence: 65%

Section: Introductionmentioning

confidence: 99%

CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration

et al. 2022

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“…This loss of time could have been avoided by direct admittance to the EVT center. On-site triage based on the severity of stroke and allocation to an EVT center has been repeatedly recommended to reduce the onset-to-treatment times but is only reluctantly accepted (23)(24)(25). Centralization of EVT in centers that are available 24/7 would help to standardize the preand intra-hospital management of these patients and facilitate treatment by highly experienced personnel.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Treatment of Acute Ischemic Stroke in Clinical Practice: Analysis of Workflow and Outcome in a Tertiary Care Center

et al. 2021

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Background and Purpose: Pre- and intra-hospital workflow in mechanical recanalization of large cervicocephalic arteries in patients with acute ischemic stroke still needs optimization. In this study, we analyze workflow and outcome in our routine care of stroke patients undergoing mechanical thrombectomy as a precondition for such optimization.Methods: Processes of pre- and intra-hospital management, causes of treatment delay, imaging results (Alberta Stroke Program Early Computed Tomography Score, localization of vessel occlusion), recanalization (modified thrombolysis in cerebral infarction score), and patient outcome (modified Rankin scale at discharge and at the end of inpatient rehabilitation) were analyzed for all patients who underwent mechanical thrombectomy between April 1, 2016, and September 30, 2018, at our site.Results: Finally, data of 282 patients were considered, of whom 150 (53%) had been referred from external hospitals. Recanalization success and patient outcome were similar to randomized controlled thrombectomy studies and registries. Delay in treatment occurred when medical treatment of a hypertensive crisis, epileptic fits, vomiting, or agitation was mandatory but also due to missing prenotification of the hospital emergency staff by the rescue service, multiple mode or repeated brain imaging, and transfer from another hospital. Even transfer from external hospitals located within a 10-km radius of our endovascular treatment center led to a median increase of the onset-to-groin time of ~60 min.Conclusion: The analysis revealed several starting points for an improvement in the workflow of thrombectomy in our center. Analyses of workflow and treatment results should be carried out regularly to identify the potential for optimization of operational procedures and selection criteria for patients who could benefit from endovascular treatment.

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“…The triage of stroke patients with large vessel occlusion has been of increasing interest in recent years 12. It is well established that the transfer of stroke patients from primary stroke centers to a CSC is time consuming, given the required coordination of interhospital transport and patient preparation for the transfer 6 17 21 24–27. The degree to which these activities prolong time to treatment are even more apparent for patients living in rural areas 9…”

Section: Discussionmentioning

confidence: 99%

“…The results of this triage concept have been published under varying names, such as drip and drive, trip and treat, Mobile Interventional Stroke Team model, drive the doctor, and drive and retrieve 13–20. These studies have demonstrated that EXT can save time compared with DS in those geographical regions 21. However, the EXT concept has not been considered in national or international stroke guidelines 2 22…”

Section: Introductionmentioning

confidence: 99%

Transferring neurointerventionalists saves time compared with interhospital transfer of stroke patients for endovascular thrombectomy: a collaborative pooled analysis of 1001 patients (EVEREST)

Şeker

Fifi

Morey

et al. 2022

J NeuroIntervent Surg

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BackgroundInterhospital transfer of stroke patients (drip and ship concept) is associated with longer treatment times compared with primary admission to a comprehensive stroke center (mothership concept). In recent years, studies on a novel concept of performing endovascular thrombectomy (EVT) at external hospitals (EXT) by transferring neurointerventionalists, instead of patients, have been published. This collaborative study aimed at answering the question of whether EXT saves time in the workflow of acute stroke treatment across various geographical regions.MethodsThis was a patient level pooled analysis of one prospective observational study and four retrospective cohort studies, the EVEREST collaboration (EndoVascular thrombEctomy at Referring and External STroke centers). Time from initial stroke imaging to EVT (vascular puncture) was compared in mothership, drip and ship, and EXT concepts.ResultsIn total, 1001 stroke patients from various geographical regions who underwent EVT due to large vessel occlusion were included. These were divided into mothership (n=162, 16.2%), drip and ship (n=458, 45.8%), and EXT (n=381, 38.1%) cohorts. The median time periods from onset to EVT (195 min vs 320 min, p<0.001) and from imaging to EVT (97 min vs 184 min, p<0.001) in EXT were significantly shorter than for drip and ship thrombectomy concept.ConclusionsThis pooled analysis of the EVEREST collaboration adds evidence that performing EVT at external hospitals can save time compared with drip and ship across various geographical regions. We encourage conducting randomized controlled trials comparing both triage concepts.

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Leaving No Large Vessel Occlusion Stroke Behind

Cited by 15 publications

References 63 publications

CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration

CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration

Endovascular Treatment of Acute Ischemic Stroke in Clinical Practice: Analysis of Workflow and Outcome in a Tertiary Care Center

Transferring neurointerventionalists saves time compared with interhospital transfer of stroke patients for endovascular thrombectomy: a collaborative pooled analysis of 1001 patients (EVEREST)

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