TY - JOUR
T1 - 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)
AU - STRATIS Investigators
AU - Froehler, Michael T.
AU - Saver, Jeffrey L.
AU - Zaidat, Osama O.
AU - Jahan, Reza
AU - Aziz-Sultan, Mohammad Ali
AU - Klucznik, Richard P.
AU - Haussen, Diogo C.
AU - Hellinger, Frank R.
AU - Yavagal, Dileep R.
AU - Yao, Tom L.
AU - Liebeskind, David S.
AU - Jadhav, Ashutosh P.
AU - Gupta, Rishi
AU - Hassan, Ameer E.
AU - Martin, Coleman O.
AU - Bozorgchami, Hormozd
AU - Kaushal, Ritesh
AU - Nogueira, Raul G.
AU - Gandhi, Ravi H.
AU - Peterson, Eric C.
AU - Dashti, Shervin R.
AU - Given, Curtis A.
AU - Mehta, Brijesh P.
AU - Deshmukh, Vivek
AU - Starkman, Sidney
AU - Linfante, Italo
AU - McPherson, Scott H.
AU - Kvamme, Peter
AU - Grobelny, Thomas J.
AU - Hussain, Muhammad S.
AU - Thacker, Ike
AU - Vora, Nirav
AU - Chen, Peng Roc
AU - Monteith, Stephen J.
AU - Ecker, Robert D.
AU - Schirmer, Clemens M.
AU - Sauvageau, Eric
AU - Abou-Chebl, Alex
AU - Derdeyn, Colin P.
AU - Maidan, Lucian
AU - Badruddin, Aamir
AU - Siddiqui, Adnan H.
AU - Dumont, Travis M.
AU - Alhajeri, Abdulnasser
AU - Taqi, M. Asif
AU - Asi, Khaled
AU - Carpenter, Jeffrey
AU - Boulos, Alan
AU - Jindal, Gaurav
AU - Kallmes, David F.
N1 - Publisher Copyright:
© 2017 The Authors.
PY - 2017/12/12
Y1 - 2017/12/12
N2 - 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.
AB - 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.
KW - emergency medical services
KW - endovascular treatment
KW - ischemic stroke
KW - stent retriever
KW - systems of care
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U2 - 10.1161/CIRCULATIONAHA.117.028920
DO - 10.1161/CIRCULATIONAHA.117.028920
M3 - Article
C2 - 28943516
AN - SCOPUS:85039071190
SN - 0009-7322
VL - 136
SP - 2311
EP - 2321
JO - Circulation
JF - Circulation
IS - 24
ER -