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      Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

      research-article
      Author(s): , MD, PhD 1 , , , MD 2 , , MD 3 , , MD 2 , , MD 4 , , MD 5 , , MD 6 , , MD, PhD 7 , , MD 8 , , MD 9 , , MD 2 , , MD, PhD 10 , , MD 11 , , DO 12 , , MD 13 , , MD 14 , , MD 15 , , MD 6 , , MD 7 , , MD 8 , , MD, PhD 9 , , MD 16 , , MD 17 , , MD 18 , , MD 2 , , MD 19 , , MD 20 , , MD 21 , , MD 22 , , MD 23 , , MD 24 , , MD 25 , , MD 26 , , MD 27 , , MD 28 , , MD, PhD 29 , , MD 30 , , MD 31 , , MD 32 , , MD 33 , , MD 34 , , MD, PhD 35 , , MD 36 , , MD 37 , , MD 38 , , MD 39 , , MD 40 , , MD 41 , , MD 42 , , MD 43 , , MD 1 , , MD 44 , , MD 45 , , MD 46 , , MD 47 , , MD 48 , , MD 49 , , MD 50 , , MD 51 , , MD 52 , , MD 53 , , MD 54 , , MD, , MD 15
      Publication date (Electronic):
      Journal: Circulation
      Publisher: Lippincott Williams & Wilkins
      Keywords: emergency medical services, endovascular treatment, ischemic stroke, stent retriever, systems of care

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Background:

          Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.

          Methods:

          STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.

          Results:

          A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.

          Conclusions:

          In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.

          Clinical Trial Registration:

          URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.

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          Most cited references19

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          Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study

          Valery L. Feigin, Rita V Krishnamurthi, Priya Parmar … (2015)
          Background: Global stroke epidemiology is changing rapidly. Although age-standardized rates of stroke mortality have decreased worldwide in the past 2 decades, the absolute numbers of people who have a stroke every year, and live with the consequences of stroke or die from their stroke, are increasing. Regular updates on the current level of stroke burden are important for advancing our knowledge on stroke epidemiology and facilitate organization and planning of evidence-based stroke care. Objectives: This study aims to estimate incidence, prevalence, mortality, disability-adjusted life years (DALYs) and years lived with disability (YLDs) and their trends for ischemic stroke (IS) and hemorrhagic stroke (HS) for 188 countries from 1990 to 2013. Methodology: Stroke incidence, prevalence, mortality, DALYs and YLDs were estimated using all available data on mortality and stroke incidence, prevalence and excess mortality. Statistical models and country-level covariate data were employed, and all rates were age-standardized to a global population. All estimates were produced with 95% uncertainty intervals (UIs). Results: In 2013, there were globally almost 25.7 million stroke survivors (71% with IS), 6.5 million deaths from stroke (51% died from IS), 113 million DALYs due to stroke (58% due to IS) and 10.3 million new strokes (67% IS). Over the 1990-2013 period, there was a significant increase in the absolute number of DALYs due to IS, and of deaths from IS and HS, survivors and incident events for both IS and HS. The preponderance of the burden of stroke continued to reside in developing countries, comprising 75.2% of deaths from stroke and 81.0% of stroke-related DALYs. Globally, the proportional contribution of stroke-related DALYs and deaths due to stroke compared to all diseases increased from 1990 (3.54% (95% UI 3.11-4.00) and 9.66% (95% UI 8.47-10.70), respectively) to 2013 (4.62% (95% UI 4.01-5.30) and 11.75% (95% UI 10.45-13.31), respectively), but there was a diverging trend in developed and developing countries with a significant increase in DALYs and deaths in developing countries, and no measurable change in the proportional contribution of DALYs and deaths from stroke in developed countries. Conclusion: Global stroke burden continues to increase globally. More efficient stroke prevention and management strategies are urgently needed to halt and eventually reverse the stroke pandemic, while universal access to organized stroke services should be a priority.
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            Analysis of Workflow and Time to Treatment and the Effects on Outcome in Endovascular Treatment of Acute Ischemic Stroke: Results from the SWIFT PRIME Randomized Controlled Trial.

            Mayank Goyal, Ashutosh Jadhav, Alain Bonafe … (2016)
            Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps. Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances. Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P < .001). Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. (©) RSNA, 2016 Online supplemental material is available for this article.
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              Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke.

              Gaspard Gerschenfeld, Ioan-Paul Muresan, Raphaël Blanc … (2017)
              Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Circulation
                Journal ID (iso-abbrev): Circulation
                Journal ID (publisher-id): CIR
                Title: Circulation
                Publisher: Lippincott Williams & Wilkins
                ISSN (Print): 0009-7322
                ISSN (Electronic): 1524-4539
                Publication date (Print): 12 December 2017
                Publication date (Electronic): 11 December 2017
                Volume: 136
                Issue: 24
                Pages: 2311-2321
                Affiliations
                [1]1Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.).
                [2]2University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.).
                [3]3St Vincent Mercy Hospital, Toledo, OH (O.O.Z.).
                [4]4Brigham and Women’s Hospital, Boston, MA (M.A.A.-S.).
                [5]5Methodist Hospital, Houston, TX (R.P.K.).
                [6]6Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.).
                [7]7Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.).
                [8]8University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.).
                [9]9Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.).
                [10]10University of Pittsburgh Medical Center, PA (A.P.J.).
                [11]11WellStar Neurosciences Network, WellStar Kennestone Regional Medical Center, Marietta, GA (R.G.).
                [12]12Valley Baptist Medical Center, Harlingen, TX (A.E.H.).
                [13]13St. Luke’s Hospital of Kansas City, MO (C.O.M.).
                [14]14Oregon Health and Science University Hospital, Portland (H.B.).
                [15]15Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., N.H.M.-K.).
                [16]16Baptist Health Lexington/Central Baptist, KY (C.A.G.).
                [17]17South Broward Hospital, Hollywood, FL (B.P.M.).
                [18]18Providence St Vincent Medical Center, Portland, OR (V.D.).
                [19]19Baptist Hospital of Miami, FL (I.L.).
                [20]20St Dominic’s-Jackson Memorial Hospital, MS (S.H.M.).
                [21]21University of Tennessee Medical Center, Knoxville (P.K.).
                [22]22Advocate Christ Medical Center, Oak Lawn, IL (T.J.G.).
                [23]23Cleveland Clinic, OH (M.S.H.).
                [24]24Baylor University Medical Center, Dallas, TX (I.T.).
                [25]25OhioHealth Riverside Methodist Hospital, Columbus (N.V.).
                [26]26Memorial Hermann Texas Medical Center, Houston (P.R.C.).
                [27]27Swedish Medical Center First Hill Campus, Seattle, WA (S.J.M.).
                [28]28Maine Medical Center, Portland (R.D.E.).
                [29]29Geisinger Clinic, Danville, PA (C.M.S.).
                [30]30Baptist Medical Center–Jacksonville, FL (E.S.).
                [31]31Baptist Hospital Louisville, KY (A.A.-C.).
                [32]32Barnes Jewish Hospital, St Louis, MO (C.P.D.).
                [33]33Mercy San Juan Medical Center and Mercy General, Carmichael, CA (L.M.).
                [34]34Presence St Joseph Medical Center, Joliet, IL (A.B.).
                [35]35Buffalo General Medical Center, NY (A.H.S.).
                [36]36University of Arizona Medical Center, Tucson (T.M.D.).
                [37]37University of Kentucky Hospital, Lexington (A.A.).
                [38]38Los Robles Medical Center, Thousand Oaks, CA (M.A.T.).
                [39]39Aurora Hospital, Milwaukee, WI (K.A.).
                [40]40West Virginia University/Ruby Memorial Hospital, Morgantown (J.C.).
                [41]41Albany Medical Center, NY (A.B.).
                [42]42University of Maryland Medical Center, Baltimore (G.J.).
                [43]43University of Massachusetts Memorial Medical Center, Worcester (A.S.P.).
                [44]44Crouse Hospital, Syracuse, NY (E.M.D.).
                [45]45Virginia Mason Medical Center, Seattle, WA (D.H.R.).
                [46]46Mayo Clinic–Rochester, MN (D.F.K.).
                [47]47Erlanger Medical Center, Chattanooga, TN (B.W.B.).
                [48]48ProMedica Toledo Hospital, OH (M.A.J.).
                [49]49Banner University Medical Center, Phoenix, AZ (P.S.).
                [50]50McLaren Flint, MI (A.M.).
                [51]51California Pacific Medical Center, San Francisco, CA (J.D.E.).
                [52]52University of California, Irvine, Orange (S.S.).
                [53]53St John Providence Hosptial, Detroit, MI (R.D.F.).
                [54]54Abbott Northwestern Hospital, Minneapolis, MN (J.E.D.A.). Carolinas Medical Center, Charlotte, NC.
                Author notes
                Correspondence to: Michael T. Froehler, MD, PhD, Cerebrovascular Program, Vanderbilt University Medical Center, A0118 Med Center North, Nashville, TN 37232. E-mail m.froehler@ 123456vanderbilt.edu
                Article
                Accession ID: 00004
                DOI: 10.1161/CIRCULATIONAHA.117.028920
                PMC ID: 5732640
                PubMed ID: 28943516
                SO-VID: 7dc55cc5-9dca-40c6-8c17-6a31c989fec9
                Copyright © © 2017 The Authors.
                License:

                Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited.

                History
                Date received : 18 April 2017
                Date accepted : 8 September 2017
                Categories
                Subject: 10021
                Subject: 10178
                Subject: Original Research Articles
                Custom metadata
                CME CME
                OPEN-ACCESS TRUE

                Keywords: emergency medical services,endovascular treatment,ischemic stroke,stent retriever,systems of care
                Data availability:
                Keywords: emergency medical services, endovascular treatment, ischemic stroke, stent retriever, systems of care

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