Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis

Comparison between "Mothership" and "Drip and Ship" models in the management of acute ischemic strokes eligible for mechanical thrombectomy in the Charleroi area, Belgium

BACKGROUND

In the management of acute ischemic stroke with large vessel occlusion (LVO-AIS), current data are conflicting as to whether a mothership model of management (MS) is associated with better functional recovery than a drip-and-ship model (DS).

METHOD

Files from LVO-AIS patients treated with MT at CHU Charleroi were analyzed between 01/01/2017 and 12/31/2022. Consecutive patients with a LVO-AIS of the anterior circulation and a prestroke modified Rankin Scale (mRS) ≤2 were included. The study's primary endpoint was the functional independence, defined as a mRS of 0-2 at 3 months post-stroke. Times metrics of MT and thrombolysis application, safety outcome including symptomatic intracranial hemorrhage and death were recorded. We conducted similar analyses by dividing DS patients, depending of their transfer time (less or >20 min). Logistic regression was used to assess if differences in baseline characteristics affected the primary outcome.

RESULTS

366 patients were included: 229 in the DS group and 137 in the MS group. Demographic data showed a higher rate of tobacco use and lower functional status prestroke in the MS population. The MS group demonstrated better performance in time metrics related to thrombolysis and MT administration. The proportion of patients achieving an mRS of 0-2 at 3 months was similar in the DS and MS groups (50.22 % vs. 48.17 %, p = 0.706). The same conclusions were drawn from the subgroup analysis. Logistic regression analysis showed no impact of baseline characteristic differences on the primary outcome.

CONCLUSION

Despite faster access to MT in the MS model, our study did not find any significant differences in functional recovery at three months post-stroke between the MS and DS management models. Our data suggest further that the prestroke health status was an important factor influencing functional outcomes after LVO-AIS.

Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS.

METHODS

A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated.

RESULTS

Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity.

CONCLUSION

3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.

Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR): study protocol for a diagnostic accuracy study

INTRODUCTION

Large-vessel occlusion (LVO) stroke is effectively treated by time-critical thrombectomy, a highly specialised procedure only available in a limited number of centres. Many patients with suspected stroke are admitted to their nearest hospital and require transfer to access treatment, with resulting delays. This study is evaluating the accuracy of a new rapid portable test for LVO stroke which could be used in the future to select patients for direct admission to a thrombectomy centre.

METHODS AND ANALYSIS

Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR) is a prospective observational cohort study taking place in stroke units in England. Participants are adults with a new suspected stroke with at least one face, arm or speech (FAST) symptom(s) and known onset within 6 hours or last known to be well 6-24 hours ago. The index test ('LVOne test' (Upfront Diagnostics)), consists of two portable lateral flow assays which use fingerprick capillary blood to detect d-dimer and glial fibrillary acidic protein concentrations. Reference standards comprise independently adjudicated standard CT/MRI brain±CT/MR angiography with senior clinician opinion to establish: ischaemic stroke±LVO; intracerebral haemorrhage; transient ischaemic attack; stroke mimic. Analyses will report sensitivity, specificity and negative and positive predictive values for identification of LVO stroke. Powered using a primary analysis population (≥2 FAST symptoms and known onset within 6 hours), 276 participants will detect a test specificity of 92%. The broader total study population which allows evaluation of the test for milder symptoms and unknown onset times is estimated to be 552 participants.

ETHICS AND DISSEMINATION

Ethical (North East-Newcastle & North Tyneside 2 Research Ethics Committee (reference: 23/NE/0043), Health Research Authority and participating National Health Service Trust approvals are granted. Consent is required for enrolment. Dissemination of results will include presentations at conferences, publication in journals and plain English summaries.

TRIAL REGISTRATION NUMBER

ISRCTN12414986.

Strategies to reduce delays in delivering mechanical thrombectomy for acute ischaemic stroke - an umbrella review

Background

Mechanical thrombectomy is a time-sensitive treatment, with rapid initiation and reduced delays being associated with better patient outcomes. Several systematic reviews reported on various interventions to address delays. Hence, we performed an umbrella review of systematic reviews to summarise the current evidence.

Methods

Medline, Embase, Cochrane Library and JBI were searched for published systematic reviews. Systematic Reviews that detailed outcomes related to time-to-thrombectomy or functional independence were included. Methodological quality was assessed using the JBI critical appraisal tool by two independent reviewers.

Results

A total of 17 systematic reviews were included in the review. These were all assessed as high-quality reviews. A total of 13 reviews reported on functional outcomes, and 12 reviews reported on time-to-thrombectomy outcomes. Various interventions were identified as beneficial. The most frequently reported beneficial interventions that improved functional and time-related outcomes included: direct-to-angio-suite and using a mothership model (compared to drip-and-ship). Only a few studies investigated other strategies including other pre-hospital and teamwork strategies.

Conclusion

Overall, there were various strategies that can be used to reduce delays in the delivery of mechanical thrombectomy with different effectiveness. The mothership model appears to be superior to the drip-and-ship model in reducing delays and improving functional outcomes. Additionally, the direct-to-angiosuite approach appears to be beneficial, but further research is required for broader implementation of this approach and to determine which groups of patients would benefit the most.

Outcome of stroke patients eligible to mechanical thrombectomy managed by spoke center, primary stroke center or comprehensive stroke center in the East of France

BACKGROUND AND PURPOSE

Patients with suspected stroke are referred to the nearest hospital and are managed either in a spoke center (SC), a primary stroke center (PSC), or a comprehensive stroke center (CSC) in order to benefit from early intravenous thrombolysis (IVT). In case of large vessel occlusion (LVO), mechanical thrombectomy (MT) is only performed in the CSC, whereas the effectiveness of MT is highly time-dependent. There is a debate about the best management model of patients with suspected LVO. Therefore, we aimed to compare functional and safety outcomes of LVO patients eligible for MT managed through our regional telestroke system.

METHOD

We performed a retrospective analysis of our observational prospective clinical registry in all consecutive subjects with LVO within six hours of onset who were admitted to the SC, PSC, or CSC in the east of France between October 2017 and November 2022. The primary endpoint was the functional independence defined as modified Rankin scale (mRS) score 0 to 2 at 90 days. Secondary endpoints were functional outcome, early neurological improvement, symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS

Among the 794 included patients with LVO who underwent MT, 122 (15.4%) were managed by a SC, 403 (50.8%) were first admitted to a PSC, and 269 (33.9%) were first admitted to the CSC. The overall median NIHSS and ASPECTS score were 16 and 8, respectively. Multivariate analysis did not find any significant difference for the primary endpoint between patients managed by PSC versus CSC (OR 1.06 [95% CI 0.64;1.76], P=0.82) and between patient managed by SC versus CSC (OR 0.69 [0.34;1.40], P=0.30). No difference between the three groups was found except for the parenchymal hematoma rate between PSC and CSC (15.7 versus 7.4%, OR 2.25 [1.07;4.74], P=0.032).

CONCLUSIONS

Compared with a first admission to a CSC, the clinical outcomes of stroke patients with LVO eligible for MT first admitted to a SC or a PSC are similar.

Impact of Direct Transport to Thrombectomy-Capable Center vs. Nearby/Distant Local Stroke Centers on Stroke Outcome in Patients Undergoing Thrombectomy: A Real-Life Study

Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical thrombectomy were analyzed (February 2017-October 2021), and the outcome was considered favorable if the modified Rankin scale (mRS) score was ≤ 2 at three months. A total of 300 patients were included, 55 of which were transferred from the NH and 58 from the DH. There was a difference in the median (IQR) transfer time of 39 min between the hospitals (149 min for the NH vs. 188 min for the DH, p = 0.003). After adjusting for confounding variables, a secondary transfer from the DH, compared to a DT, was associated with a lower functional independence: mRS score ≤ 2 (OR = 0.37, 95% CI = 0.14-0.97, p = 0.043), without significant differences in the mortality between the groups. These differences were not observed in patients from the NH. Conclusions: A secondary transfer from a distant hospital was associated with a poorer functional outcome at 3 months. This unfavorable outcome was not observed among patients transferred from a nearby hospital. These findings highlight the importance of categorizing the suitability of one transfer model over another based on the proximity of hospitals to the thrombectomy center, but also in accordance with organizational and geographic characteristics that vary within each health region.

The role of intravenous thrombolysis before mechanical Thrombectomy: A subgroup analysis of the RESILIENT trial

BACKGROUND

Randomized trials have recently evaluated the non-inferiority of direct thrombectomy versus intravenous thrombolysis (IVT) followed by endovascular therapy in anterior circulation large vessel occlusion (LVO) stroke in patients eligible for IVT within 4.5 h from stroke onset with controversial results. We aimed to assess the effect of IVT on the clinical outcome of mechanical thrombectomy (MT) in the RESILIENT trial.

METHODS

RESILIENT was a randomized, prospective, multicenter, controlled trial assessing the safety and efficacy of thrombectomy versus medical treatment alone. A total of 221 patients were enrolled. The trial showed a substantial benefit of MT when added to medical management. All eligible patients received intravenous tPA within the 4.5-h-window. Ordinal logistic and binary regression analyses using intravenous tPA as an interaction term were performed with adjustments for potential confounders, including age, baseline NIHSS score, occlusion site, and ASPECTS. A p-value <0.05 was considered statistically significant.

RESULTS

Among 221 randomized patients (median NIHSS, 18 IQR [14-21]), 155 (70%) were treated with IVT. There was no difference in the mRS ordinal shift and frequency of functional independence between patients who received or not IV tPA; the odds ratio for the ordinal mRS shift was 2.63 [1.48-4.69] for the IVT group and 1.54 [0.63-3.74] for the no IVT group, with a p-value of 0.42. IVT also did not affect the frequency of good recanalization (TICI 2b or higher) and hemorrhagic transformation.

CONCLUSIONS

The large effect size of MT on LVO outcomes was not significantly affected by IVT.

TRIAL REGISTRATION

RESILIENT ClinicalTrials.gov number, NCT02216643.

Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th Edition Practice Guidelines Update, 2022

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

Comparison between different referral strategies for acute ischemic stroke patients in a hub-spoke emergency stroke network: a real-world experience in south-east Lazio

AIM

To describe different referral strategies for acute ischemic stroke (AIS) patients in a Hub-Spoke emergency stroke network with their incidence, time metrics and related outcomes.

METHODS

Referral paradigms were defined as follows: primary transfer to the comprehensive stroke center (CSC) from a remote region, called mothership (MS); secondary transfer to the CSC from a primary stroke center where intravenous thrombolysis was available, called drip and ship (DS); secondary transfer to the CSC from a community hospital where no reperfusion therapy was available, called ship and drip (SD); primary transfer to the CSC from its catchment area, called direct CSC (dCSC).

RESULTS

Among 517 anterior circulation AIS patients treated with mechanical thrombectomy between 2015 and 2020, 16.6% of them were SD, in addition to the well-known referral paradigms of MS (21.8%) and DS (18.1%). This rate grew to 30% when only patients whose place of onset was outside the CSC catchment area were considered. In the SD group, onset to CSC and onset to groin were significantly longer (178±80 min vs. 102±60 min, p<0.001, and 277±77 min vs. 211±61 min, p<0.001, respectively), and the risk of any intracranial hemorrhage (ICH) was significantly higher (OR: 2.514; 95%CI: 1.18-5.35, p=0.017) compared to MS.

CONCLUSION

In this hub-spoke stroke network, a high proportion of SD paradigm was found, which was associated with longer times to treatment and higher rates of any ICH. A closer cooperation between hospital stroke physicians, national health system staff, and paramedics is warranted to identify the most appropriate referral strategy for each patient.

Advances in mechanical thrombectomy for acute ischaemic stroke

Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Less is more - The Finnish Prehospital Stroke Scale prospective validation

OBJECTIVES

The current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers.

PATIENTS AND METHODS

The prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers.

RESULTS

In Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage.

CONCLUSIONS

FPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.

Clinical outcome, recanalization success, and time metrics in drip-and-ship vs. drive-the-doctor: A retrospective analysis of the HEI-LU-Stroke registry

Purpose

This study aimed at comparing clinical outcome, recanalization success and time metrics in the “drip and ship” (DS) vs. “drive the doctor” (DD) concept in a comparable setting.

Methods

This is a retrospective analysis of thrombectomy registries of a comprehensive stroke center (CSC) and a thrombectomy-capable stroke center (TSC). Patients, who were transferred from the TSC to the CSC, were classified as DS. Patients treated at the TSC by an interventionalist transferred from the CSC were classified as DD. Good outcome was defined as mRS 0–2 or equivalent to premorbid mRS at discharge. Recanalization (TICI 2b-3 or equivalent) and time metrics were compared in both groups.

Results

In total, 295 patients were included, of which 116 (39.3%) were treated in the DS concept and 179 (60.7%) in the DD concept. Good clinical outcome was similarly achieved in DS and DD (DS 25.0% vs. DD 31.3%, P = 0.293). mRS on discharge (DS median 4, DD median 4, P = 0.686), NIHSS improvement (DS median 4, DD median 5, P = 0.582) and NIHSS on discharge (DS median 9, DD median 7, P = 0.231) were similar in both groups. Successful reperfusion was achieved similarly in DS (75.9%) and DD as well (81.0%, P = 0.375). Time from onset to reperfusion (median DS 379 vs. DD 286 min, P = 0.076) and time from initial imaging to reperfusion were longer in DS compared to DD (median DS 246 vs. DD 162 min, P &lt; 0.001).

Conclusion

The DD concept is time saving while achieving similar clinical outcome and recanalization results.

Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia

BACKGROUND

We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020.

METHODS

We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am-8:59 pm) and nighttime (9:00 pm-7:59 am). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated.

RESULTS

We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020-2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680-1.163]; P _interaction=0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548-1.072]; nighttime, acOR, 1.785 [95% CI, 1.024-3.112] ; P _interaction<0.01); no heterogeneity was observed for other stroke subtypes (P _interaction>0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers.

CONCLUSIONS

Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02795962.

Decompressive Hemicraniectomy in the Stroke Patient

Decompressive hemicraniectomy (DHC) is a life-saving procedure involving removal of large portions of the skull to relieve intracranial pressure in patients with space occupying cerebral edema such as traumatic brain injury (TBI) and stroke. Although the procedure has been shown to decrease mortality in patients, the risk of severe disability is significant. Quality of life, not just survival, following DHC has emerged as an important consideration when the decision is made to perform a DHC.

Factors associated with the time from the first call to emergency medical services to puncture for mechanical thrombectomy for ischaemic stroke patients in Gironde, France, in 2017 and 2018

BACKGROUND AND PURPOSE

When an ischaemic stroke due to a large vessel occlusion occurs, the sooner Mechanical Thrombectomy (MT) is performed, the better the functional prognosis. However, the organisation of care does not systematically allow rapid access to MT. The aim of our study was to determine the clinical and organisational factors associated with the time to access to MT.

METHODS

We conducted a cohort study in Gironde County, France. Patients admitted for MT and regulated by the Gironde Emergency Medical Services (EMS) between 01/01/2017 and 31/12/2018 were included. The time to access to MT was the difference between the first call to EMS and groin puncture for MT. The main explanatory variables were: type of pathway (mothership (MS), drip and ship (DS) with cerebral imaging performed in the local hospital centre (LHC), and DS without imaging in the LHC); NIHSS score; driving distance to MT; time of stroke onset (weekend or holiday, school holidays, other); age and sex. Linear regression models were used to explain time to access to MT. Missing data were handled using a multiple imputation procedure (Full conditional specification, Mice R-Package) carried out in our multivariable linear regression model. A quantitative bias analysis was performed by weighing the imputed time to access to MT and identifying the weight changing the conclusions of our analysis.

RESULTS

Among the 314 included patients, 152 were women (48.4%), and the mean NIHSS score was 16.4. Two hundred and two (64.3%) patients were managed through the MS pathway. The average time from onset to femoral puncture was 251 minutes. In the multivariate analysis, the time to MT was longer when patients were managed DS with imaging in the LHC pathway (+106 min, p = 0.03), and even longer in the DS without imaging in the LHC pathway (+197 min, p = 0.002), compared with MS. Time from onset to MT decreased with increasing NIHSS score (-6 min per NIHSS point, p <.0001). In our quantitative bias analysis, we multiplied the imputed time in access to MT in the DS pathways only (with or without imaging in the LHC) by weights varying from 0.9 to 0.2 (imputed delays reduced from 10% to 80%). With reduction of 40% or more, there was no longer any difference in time to access to MT between the three studied pathways.

CONCLUSIONS

The DS pathway can be shortened by generalizing access to cerebral imaging in LHCs. Optimizing pre-admission orientation toward MT is a major issue in LVOS management.

Mothership vs. drip-and-ship: evaluation of initial treatment strategies for acute ischemic stroke in a well-developed network of specialized hospitals

PURPOSE

Two strategies of initial patient care exist in endovascular thrombectomy (ET) depending on the site of initial admission: the mothership (MS) and drip-and-ship (DnS) principles. This study compares both strategies in regard to patient outcome in a local network of specialized hospitals.

METHODS

Two-hundred-and-two patients undergoing ET in anterior circulation ischemic stroke between June 2016 and May 2018 were enrolled. Ninety two patients were directly admitted to our local facility (MS), One-hundred-and-ten were secondarily referred to our facility. Group comparisons between admission strategies in three-months modified Rankin Scale (mRS), Maas Score and Alberta-Stroke-Program-Early-computed-tomography-score (ASPECTS), National-Institutes-of-Health-Stroke-Scale (NIHSS), age and onset-to-recanalization-time were performed. Correlation between admission strategy and mRS was calculated. A binary logistic regression model was computed including mRS as dependent variable.

RESULTS

There were neither significant group differences in three-months mRS between MS and DnS nor significant correlations. Patients tended to achieve a better outcome with DnS. Collateralization status differed between MS and DnS (p = 0.003) with better collateralization in DnS. There were no significant group differences in NIHSS or ASPECTS but in onset-to-recanalization-time (p < 0.001) between MS and DnS. Binary logistic regression showed a high explanation of variance of mRS but no significant results for admission strategy.

CONCLUSIONS

Functional outcome in patients treated with ET is comparable between the MS and DnS principles. Tendentially better outcome in the DnS subgroup may be explained by selection bias due to a higher willingness to apply ET in patients with worse baseline conditions (e.g. worse collateralization), if patients undergoing MS are already on site.

Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region

Introduction Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region. Methods We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke. Results We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes. Conclusion Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.

Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area

BACKGROUND

Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs).

METHODS

We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis.

RESULTS

The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization.

CONCLUSION

EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Validation of a cloud-based tele-stroke system reliability in determining national institutes of health stroke scale scores for acute ischemic stroke screening in the emergency department

Background and purpose

The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for objectively quantifying the impairment caused by a suspected stroke. Nevertheless, it is mainly used by trained neurologists in the emergency department (ED). To bring forward the NIHSS to the pre-hospital setting, a smartphone-based Telestroke system was developed. It captures the full NIHSS by video, transmits it off-line, and enables assessment by a distant stroke physician. We aimed to compare the reliability of an NIHSS score determined by a neurologist from afar, using the platform with a standard NIHSS assessment performed in the emergency departments.

Methods

A multi-center prospective study was conducted in two centers (Vall d'Hebron, Barcelona, and Rambam, Israel). Patients admitted to the ED with suspected stroke had a neurological exam based on the NIHSS, while being recorded by the system. A skilled neurologist rated the NIHSS according to the videos offline. The results were compared with the NIHSS score given by a neurologist at the bedside.

Results

A total of 95 patients with suspected stroke were included. The overall intraclass correlation coefficient was 0.936 (0.99 in VdH and 0.84 in Rambam), indicating excellent and good reliability, respectively.

Conclusion

Remote stroke assessment based on the NIHSS, using videos segments collected by a dedicated platform, installed on a standard smartphone, is a reliable measurement as compared with the bedside evaluation.

The Hunter-8 scale prehospital triage workflow for identification of large vessel occlusion and brain haemorrhage

ObjectiveThe Hunter-8 prehospital stroke scale predicts large vessel occlusion in hyperacute ischemic stroke patients (LVO) at hospital admission. We wished to test its performance in the hands of paramedics as part of a prehospital triage algorithm. We aimed to determine a) the proportion of patients identified by the Hunter-8 algorithm, receiving reperfusion therapies, b) whether a call to stroke team improved this, and c) performance for LVO detection using an expanded LVO definition.MethodsA prehospital workflow combining pre-morbid functional status, time from symptom onset, and the Hunter-8 scale was implemented from July 2019. A telephone call to the stroke team was prompted for potential treatment candidates. Classic LVO was defined as a proximal middle cerebral artery (MCA-M1), terminal internal carotid artery, or tandem occlusion. Extended LVO added proximal MCA-M2 and basilar occlusions.ResultsFrom July 2019 to April 2021, there were 363 Hunter-8 activations, 320 analysed: 181 (56.6%) had confirmed ischemic strokes, 13 (4.1%) transient ischemic attack, 91 (28.5%) stroke mimics, and 35 (10.9%) intracranial haemorrhage. Fifty-two patients (16.3%) received reperfusion therapies, 35 with Hunter-8 ≥ 8. The stroke doctor changed the final destination for 76 patients (23.7%), and five received reperfusion therapies. The AUCs for classic and extended LVO were 0.73 (95% CI 0.66-0.79) and 0.72 (95% CI 0.65-0.77), respectively.ConclusionThe Hunter-8 workflow resulted in 28.7% of confirmed ischemic stroke patients receiving reperfusion therapies, with no secondary transfers to the comprehensive stroke centre. The role of communication with stroke team needs to be further explored.

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

Introduction

Shortening the time from stroke onset to treatment increases the effectiveness of endovascular stroke therapies.

Aim

This study aimed to predict the modified Rankin Scale score at 90 days post-stroke (mRS-90d score) in patients with acute ischaemic stroke (AIS) with respect to four types of treatment: conservative therapy (CVT), intravenous thrombolysis only (IVT), mechanical thrombectomy only (MT) and pretreatment with IVT before MT (IVT+MT).

Patients and methods

This nationwide observational study included 124 484 confirmed cases of acute stroke in Sweden over 6 years (2012–2017). The associations between onset-to-treatment time (OTT), patient age and hospital admission National Institutes of Health Stroke Scale (NIHSS) score with the five-levelled mRS-90d score were retrospectively studied. A generalised linear model (GLM) was fitted to predict the mRS-90d scores for each patient group.

Results

The fitted GLM for CVT patients is a function of age and NIHSS score. For IVT, MT and IVT+MT patients, GLMs additionally employed OTT variables. By reducing the mean OTTs by 15 min, the number needed-to-treat (NNT) for one patient to make a favourable one-step shift in the mRS was 30 for IVT, 48 for MT and 21 for IVT+MT.

Discussion and conclusion

This study demonstrates linear associations of mRS-90d score with OTT for IVT, MT and IVT+MT, and shows in absolute effects measures that OTT reductions for IVT and/or MT produces substantial health gains for patients with AIS. Even moderate OTT reductions led to sharp drops in the NNT.

Direct to Angiosuite Versus Conventional Imaging in Suspected Large Vessel Occlusion: A Systemic Review and Meta-Analysis

BACKGROUND

There is growing evidence to suggest that the direct transfer to angiography suite (DTAS) approach for patients with suspected large vessel occlusion stroke potentially requiring mechanical thrombectomy shortens treatment times and improves outcomes compared with the direct transfer to conventional imaging (DTCI) model. Therefore, we conducted this meta-analysis to compare both approaches to build more concrete evidence to support this innovative treatment concept.

METHODS

All potentially relevant studies published in 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021 were reviewed. Eligible studies were included if they enrolled ≥10 patients in both groups, were published in English, and reported baseline and procedural characteristics and outcomes. Relevant data were then extracted and analyzed.

RESULTS

Among 4514 searched studies, 7 qualified for the analysis with 1971 patients (DTAS=675, DTCI=1296). Times from door to puncture (mean difference, -30.76 minutes [95% CI, -43.70 to -17.82]; P<0.001) as well as door-to-reperfusion (mean difference=-33.24 minutes [95% CI, -51.82 to -14.66]; P<0.001) were significantly shorter and the rates of functional independence (modified Rankin Scale score, 0-2: risk ratio [RR], 1.25 [95% CI, 1.02-1.53]; P=0.03) at 90 days were higher in the DTAS versus the DTCI approach. There was no difference across the DTAS and DTCI groups in terms of the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2B-3: RR, 1.03 [95% CI, 0.95-1.12]; P=0.42), near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction 2C-3: RR, 0.89 [95% CI, 0.74-1.08]; P=0.23), symptomatic intracranial hemorrhage (RR, 0.81 [95% CI, 0.56-1.17]; P=0.26), or fair outcomes (modified Rankin Scale score, 0-3: RR, 1.14 [95% CI, 0.88-1.47]; P=0.32) or mortality (RR, 0.98 [95% CI, 0.67-1.44]; P=0.93) at 90 days. Subgroup analysis showed no significant difference in 90-day functional independence across approaches in transfer patients (RR, 1.20 [95% CI, 0.96-1.51]; P=0.11).

CONCLUSIONS

Our meta-analysis showed that the DTAS approach seems to be associated with improved time metrics and functional outcomes with comparable safety to the DTCI approach. Ongoing multicenter randomized clinical trials will hopefully provide more definite data about this promising approach.

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

BACKGROUND

Interhospital 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.

METHODS

This 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.

RESULTS

In 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.

CONCLUSIONS

This 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.

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background

Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.

Objectives

The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.

Design

A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.

Setting

The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.

Participants

A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.

Interventions

The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.

Main outcome measures

The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.

Data sources

National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.

Review methods

Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).

Limitations

Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.

Conclusions

Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.

Future work

Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.

Trial registration

This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.

Funding

The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016

To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.

Emerging Detection Techniques for Large Vessel Occlusion Stroke: A Scoping Review

Background: Large vessel occlusion (LVO) is the obstruction of large, proximal cerebral arteries and can account for up to 46% of acute ischaemic stroke (AIS) when both the A2 and P2 segments are included (from the anterior and posterior cerebral arteries). It is of paramount importance that LVO is promptly recognised to provide timely and effective acute stroke management. This review aims to scope recent literature to identify new emerging detection techniques for LVO. As a good comparator throughout this review, the commonly used National Institutes of Health Stroke Scale (NIHSS), at a cut-off of ≥11, has been reported to have a sensitivity of 86% and a specificity of 60% for LVO. Methods: Four electronic databases (Medline via OVID, CINAHL, Scopus, and Web of Science), and grey literature using OpenGrey, were systematically searched for published literature investigating developments in detection methods for LVO, reported from 2015 to 2021. The protocol for the search was published with the Open Science Framework (10.17605/OSF.IO/A98KN). Two independent researchers screened the titles, abstracts, and full texts of the articles, assessing their eligibility for inclusion. Results: The search identified 5,082 articles, in which 2,265 articles were screened to assess their eligibility. Sixty-two studies remained following full-text screening. LVO detection techniques were categorised into 5 groups: stroke scales (n = 30), imaging and physiological methods (n = 15), algorithmic and machine learning approaches (n = 9), physical symptoms (n = 5), and biomarkers (n = 3). Conclusions: This scoping review has explored literature on novel and advancements in pre-existing detection methods for LVO. The results of this review highlight LVO detection techniques, such as stroke scales and biomarkers, with good sensitivity and specificity performance, whilst also showing advancements to support existing LVO confirmatory methods, such as neuroimaging.

Anterior circulation large vessel occlusion outcomes in patients transferred from a peripheral primary stroke centre

OBJECTIVES

To identify predictors of functional outcome in patients with an anterior circulation large-vessel occlusion (LVO) in a setting of long transfer distances.

METHODS

Outcomes of LVO patients transferred for an endovascular thrombectomy (EVT) from North Karelia Central Hospital to Kuopio University Hospital between January 2018 and October 2019 were analysed using retrospective patient chart review.

RESULTS

Three months after the stroke, modified Rankin Scale (mRS) was 0-2 in 20 of the 41 transferred patients. They were younger (66.7 vs. 74.2 years, p = 0.032) and had less severe stroke symptoms (National Institutes of Health Stroke Scale, NIHSS, 11.5 vs. 16.5, p = 0.029) than those with mRS 3-6. They also had the occlusion less often in M1 and more often in M2. EVT was performed in 32 patients (no differences between those treated with EVT and those not treated with EVT). Their median age was 73.0 years (interquartile range 65.5, 79.8; range 32-86; 25% over 80), mean NIHSS score 14.0 (standard deviation 5.9) and mRS eventually 0-2 in 44%. Only NIHSS was associated with mRS (OR = 1.16; p = 0.016) in the EVT-treated patients. mRS was 0 in 38% of all EVT-treated octogenarians but 4-6 in 83% of those with an internal carotid artery and/or M1 occlusion.

DISCUSSION

Outcomes depended on stroke severity, age and vessel of occlusion. Prognosis was worse if the occlusion included M1, especially in octogenarians. Mothership and Drip-n-ship strategies should be compared in patients from remote locations stratified by stroke severity and patient age.

Modeling the Impact of Prehospital Triage on a True-Life Drip and Ship Mechanical Thrombectomy Urban Patient Cohort

Objective

The aim of the study was to model the effect of prehospital triage of emergent large vessel occlusion (ELVO) to endovascular capable center (ECC) on the timing of thrombectomy and intravenous (IV) thrombolysis using real-world data from a multihospital system.

Methods

We selected a cohort of 77 consecutive stroke patients who were brought by emergency medical services (EMS) to a nonendovascular capable center and then transferred to an ECC for mechanical thrombectomy (MT) (“actual” drip and ship [DS] cohort). We created a hypothetical scenario (bypass model [BM]), modeling transfer of the patients directly to an ECC, based on patients' initial EMS pickup address and closest ECC. Using another cohort of 73 consecutive patients, who were brought directly to an ECC by EMS and underwent endovascular intervention, we calculated mean door-to-needle and door-to-arterial puncture (AP) times (“actual” mothership [MS] cohort). Timings in the actual MS cohort and the actual DS cohort were compared to timings from the BM cohort.

Results

Median first medical contact (FMC) to IV thrombolysis time was 87.5 min (interquartile range [IQR] = 38) for the DS versus 78.5 min (IQR = 8.96) for the BM cohort, with p = 0.1672. Median FMC to AP was 244 min (IQR = 97) versus 147 min (IQR = 8.96) (p < 0.001), and median FMC to TICI 2B+ time was 299 min (IQR = 108.5) versus 197 min (IQR = 8.96) (p < 0.001) for the DS versus BM cohort, respectively.

Conclusions

Modeled EMS prehospital triage of ELVO patients' results in shorter MT times without a change in thrombolysis times. As triage tools increase in sensitivity and specificity, EMS triage protocols stand to improve patient outcomes.

Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center

Introduction: Organizing regional stroke care considering thrombolysis as well as mechanical thrombectomy (MTE) remains challenging in light of a wide range of regional population distribution. To compare outcomes of patients in a stroke network covering vast rural areas in southwestern Germany who underwent MTE via direct admission to a single comprehensive stroke center [CSC; mothership (MS)] with those of patients transferred from primary stroke centers [PSCs; drip-and-ship (DS)], we undertook this analysis of consecutive stroke patients with MTE.

Materials and Methods: Patients who underwent MTE at the CSC between January 2013 and December 2016 were included in the analysis. The primary outcome measure was 90-day functional independence [modified Rankin score (mRS) 0–2]. Secondary outcome measures included time from stroke onset to recanalization/end of MTE, angiographic outcomes, and mortality rates.

Results: Three hundred and thirty-two consecutive patients were included (MS 222 and DS 110). Median age was 74 in both arms of the study, and there was no significant difference in baseline National Institutes of Health Stroke Scale scores (median MS 15 vs. 16 DS). Intravenous (IV) thrombolysis (IVT) rates differed significantly (55% MS vs. 70% DS, p = 0.008). Time from stroke onset to recanalization/end of MTE was 112 min shorter in the MS group (median 230 vs. 342 min, p < 0.001). Successful recanalization [thrombolysis in cerebral infarction (TICI) 2b-3] was achieved in 72% of patients in the MS group and 73% in the DS group. There was a significant difference in 90-day functional independence (37% MS vs. 24% DS, p = 0.017), whereas no significant differences were observed for mortality rates at 90 days (MS 22% vs. DS 17%, p = 0.306).

Discussion: Our data suggest that patients who had an acute ischemic stroke admitted directly to a CSC may have better 90-day outcomes than those transferred secondarily for thrombectomy from a PSC.

Prehospital Stroke Triage

PURPOSE OF THE REVIEW

This article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center ("drip and ship"), direct transfer of the patient to an endovascular center ("mothership"), transfer of the neurointerventional team to a local primary center ("drip and drive"), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.

RECENT FINDINGS

Local observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.

SUMMARY

Prehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

Mechanical thrombectomy reduces the gap in treatment outcomes of ischemic stroke between hospital levels of care: analysis of a Korean nationwide data

Background

Mechanical thrombectomy (MT) of ischemic stroke was demonstrated to be effective in clinical trials and was reported to have favorable outcomes in real clinical settings since 2015. We aimed to determine the national trends of MT and compare the outcomes between the different levels of treating hospital.

Methods

We obtained data from the nationwide database from 2008 to 2017. Patients with ischemic stroke who received MT were identified using the International Classification of Disease Codes. Good outcome was defined as discharge to home, and a poor outcome was defined as cerebral hemorrhage, physical disability, or death. The study period was divided into three (off-label MT, transitional, MT period). Hospital groups where MT was performed were divided into tertiary and non-tertiary hospitals.

Results

In MT period, 47.0% of the MT procedures were performed in non-tertiary hospitals compared with 36.1% in off-label MT period. Comparison of the 3-month mortality between patients who were treated in tertiary vs. non-tertiary hospitals revealed significant lower mortality in tertiary hospital through all period. The incidence of cerebral hemorrhage and physical disability did not differ between hospital groups. However, the percentage of patients discharged home was 41.4% for tertiary hospitals and 42.4% for non-tertiary hospitals, which was not statistically different in MT period (P=0.4671).

Conclusions

Analysis of the nationwide data confirmed that the extent of increase in MT was higher in non-tertiary hospitals than tertiary hospitals. In addition, no significant difference was revealed in the number of favorable clinical outcome between the hospital groups during MT period.

Impact of the SARS-COV-2 Pandemic on the Endovascular Treatment of Acute Stroke - an Italian Single-Center Experience

Objectives

The SARS-CoV-2 pandemic greatly influenced the overall quality of healthcare. The purpose of this study was to compare the time variables for acute stroke treatment and evaluate differences in the pre-hospital and in-hospital care before and during the SARS-CoV-2 pandemic, as well as between the first and second waves.

Materials and methods

Observational and retrospective study from an Italian hospital, including patients who underwent thrombectomy between January 1st 2019 and December 31st 2020.

Results

Out of a total of 594 patients, 301 were treated in 2019 and 293 in 2020. The majority observed in 2019 came from spoke centers (67,1%), while in 2020 more than half (52%, p < 0.01) were evaluated at the hospital's emergency room directly (ER-NCGH). When compared to 2019, time metrics were globally increased in 2020, particularly in the ER-NCGH groups during the period of the first wave (N = 24 and N = 56, respectively): “Onset-to-door”:50,5 vs 88,5, p < 0,01; “Arrival in Neuroradiology – groin”:13 vs 25, p < 0,01; “Door-to-groin”:118 vs 143,5, p = 0,02; “Onset-to-groin”:180 vs 244,5, p < 0,01; “Groin-to-recanalization”: 41 vs 49,5, p = 0,03. When comparing ER-NCGH groups between the first (N = 56) and second (N = 49) waves, there was an overall improvement in times, namely in the “Door-to-CT” (47,5 vs 37, p < 0,01), “Arrival in Neuroradiology – groin” (25 vs 20, p = 0,03) and “Onset-to-groin” (244,5 vs 227,5, p = 0,02).

Conclusions

During the SARS-CoV-2 pandemic, treatment for stroke patients was delayed, particularly during the first wave. Reallocation of resources and the shutting down of spoke centers may have played a determinant role.

Efficacy and safety of bridging thrombolysis initiated before transfer in a drip-and-ship stroke service

Objective

Data regarding the efficacy and safety of bridging thrombolysis (BT) initiated before transfer for evaluation of endovascular therapy is heterogeneous. We, therefore, analyse efficacy and safety of BT in patients treated within a drip-and-ship stroke service.

Methods

Consecutive adult patients suffering from acute ischaemic stroke and large-vessel occlusions (LVO) transferred to our comprehensive stroke centre for evaluation of endovascular therapy in 2017–2020 were identified from a local prospective stroke database and categorised according to BT and no-BT. BT was defined as intravenous thrombolysis initiated before transfer. LVO was assessed before and after transfer. Functional outcome before stroke and at 3 months using the modified Rankin scale (mRS) was determined. Excellent outcome was defined as mRS 0–1 or return to prestroke mRS. For safety analysis, intracranial haemorrhages and mortality at 3 months were analysed. Main analysis was limited to patients with anterior circulation stroke.

Results

Of N=714 patients, n=394 (55.2%) received BT. More patients in the BT group with documented LVO before transfer recanalised without endovascular therapy (n=46, 11.7%) than patients who did not receive BT before transfer (n=4, 1.3%, p<0.001). In multivariate analysis, BT was the strongest independent predictor of early recanalisation (adjusted OR 10.9, 95% CI 3.8 to 31.1, p<0.001). BT tended to be an independent predictor of an excellent outcome at 3 months (adjusted OR 1.38, 95% CI 0.97 to 1.96, p=0.077). There were no differences in safety between the BT and no-BT groups.

Conclusions

BT initiated before transfer was a strong independent predictor of early recanalisation.

Emergency Care of Patients with Acute Ischemic Stroke

Stroke is a leading cause of morbidity and mortality and a major cause of long-term disability. Management of acute ischemic stroke in the first hours is critical to patient outcomes. This review provides an overview of acute ischemic stroke management, with a focus on the golden hour. Additional topics discussed include prehospital considerations and initial evaluation of the patient with history, examination, and imaging as well as treatment options, including thrombolysis and endovascular therapy.

Impact of ongoing centralization of acute stroke care from "drip and ship" into "direct-to-mothership" model in a Dutch urban area

When acute stroke care is organised using a "drip-and-ship" model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the "direct-to-mothership" model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from "drip and ship" into "direct-to-mothership". Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.

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

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from "drip and ship" to "mothership" yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

Potential accuracy of prehospital NIHSS-based triage for selection of candidates for acute endovascular stroke therapy

OBJECTIVE

Whether patients with acute stroke and large vessel occlusion (LVO) benefit from prehospital identification and diversion by emergency medical services (EMS) to an endovascular stroke therapy (EST)-capable center is controversial. We sought to estimate the accuracy of field-based identification of potential EST candidates in a hypothetical best-of-all-worlds situation.

METHODS

In Kaiser Permanente Northern California, all acute stroke patients arriving at its 21 stroke centers between 7:00 am and midnight from January 2016 to December 2019 were evaluated by teleneurologists on arrival. Initial National Institutes of Health Stroke Scale (NIHSS) score, presence of LVO, and referral for EST were obtained from standardized teleneurology notes. Factors associated with LVO were evaluated using generalized estimating equations accounting for clustering by facility.

RESULTS

Among 13,377 patients brought in by EMS with potential stroke, 7168 (53.6%) were not candidates for acute stroke interventions. Of the remaining 6089 cases, 2,573 (42.3%) had an NIHSS score >10, the cutoff with a higher association for LVO. Only 703 patients (27.3% with NIHSS score >10) were ultimately diagnosed with LVO and referred for EST. Across all NIHSS scores, only 884 (6.6%) suspected acute stroke patients had LVO and EST referral.

CONCLUSIONS

Even if field-based tools were as accurate as NIHSS scoring and predictions by stroke neurologists, only about 1 in 4 acute stroke patients diverted to EST-capable centers would benefit by receiving EST. Depending on geography and stroke center performance on door-to-needle time, many systems may be better served by focusing on expediting evaluation, treatment with intravenous thrombolysis, and transfer to EST-capable centers.

Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

Background

Evidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).

Methods

ASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.

Results

ASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R²=0.209, p<0.0001).

Conclusions

Infarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

Comparison of mothership versus drip-and-ship models in treating patients with acute ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

There is controversy if direct to comprehensive center "mothership" or stopping at primary center for thrombolysis before transfer to comprehensive center "drip-and-ship" are best models of treatment of acute stroke. In this study, we compare mothership and drip-and-ship models to evaluate the best option of functional outcome.

METHODS

Studies between 1990 and 2020 were extracted from online electronic databases. Clinical outcomes, critical time measurements, functional independence, and mortality were then compared.

RESULTS

A total of 7824 patients' data were retrieved from 13 publications (3 randomized control trials and 10 retrospective ones). In addition, 4639 (59.3%) patients were treated under mothership model, and 3185 (40.7%) followed the drip-and-ship model with mean age of 70.01 ± 3.58 versus 69.03 ± 3.36; p < 0.001, respectively. The National Institute Health Stroke Scale was 15.57 ± 3.83 for the mothership and 15.72 ± 2.99 for the drip-and-ship model (p ≤ 0.001). The mean symptoms onset-to-puncture time was significantly shorter in the mothership group compared to the drip-and-ship (159.69 min vs. 223.89 min; p ≤ 0.001, respectively). Moreover, the collected data indicated no significant difference between symptom's onset to intravenous thrombolysis time and stroke onset-to-successful recanalization time (p = 0.205 and p ≤ 0.001, respectively). Patients had significantly worse functional outcome (modified Rankin score) (3-6) at 90 days in the drip-and-ship model (odds ratio (OR): 1.47, 95% confidence interval (CI): 1.13-1.92, p < 0.004) and 1.49-folds higher likelihood of symptomatic intracerebral hemorrhage (OR: 1.49, 95% CI: 1.22-1.81, p < 0.0001) compared to mothership. However, there were no statistically significant difference in terms of mortality (OR: 1.16, 95% CI: 0.87-1.55, p = 0.32) and successful recanalization (OR: 1.12, 95% CI: 0.76-1.65, p = 0.56) between the two models of care.

CONCLUSION

Patients in the mothership model have significantly improved functional independence and recovery. Further studies are needed as the data from prospectively randomized studies are not of sufficient quality to make definite recommendations.

"Thrombectomy and Back:" A Novel Approach for Treating Patients with Large Vessel Occlusion in the Eastern Province of Saudi Arabia

Background:

Timely access to comprehensive stroke centers for patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) remains a commonly encountered obstacle worldwide, especially in areas with no comprehensive stroke or thrombectomy-capable stroke centers.

Objective:

To present our novel experience with a “thrombectomy-and-back” model implemented in the Eastern Province of Saudi Arabia.

Methods:

King Fahd Hospital of the University (KFHU), a 600-bed hospital located in Al Khobar with an open-access emergency department, was designated as a comprehensive stroke center in the Eastern Province. “Thrombectomy-and-back” was designed such that the neurologist in the referring hospital directly communicates with the attending neurovascular team at KFHU for their anticipation of the case, and subsequently confirms LVO presence through urgent acquisition of a CT and a CT angiogram. Once LVO was confirmed, the patients were timely transferred to KFHU for mechanical thrombectomy. Upon procedure completion, the patients returned to the referring hospital with the same medical and EMS team. The safety of transfer and peri-procedural complications were analyzed.

Results:

From December 2017 to December 2019, 20 thrombectomy-and-back codes were activated, of which 10 were deactivated on negative LVO and 10 remained activated. Of these 10 patients, 2 required admission to our hospital's Neuro-ICU: one was because the middle cerebral artery reoccluded during the procedure and the other was due to hemodynamic instability upon arrival; this first patient passed away 2 months later due to the complications of the malignant left middle cerebral artery stroke.

Conclusions:

The novel Thrombectomy-and-Back model in the Eastern Province of Saudi Arabia has proved to be a safe and efficient approach for patients presenting with LVO to receive timely interventional therapy and minimizing futile transfers.

Optimal patient protocols in regional acute stroke care

In acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be given in a stroke centre with specialized facilities. Rapid initiation of either is key to improving the functional outcome (often emphasized by the common phrase in acute stroke care "time=brain"). Delays between the moment the ambulance is called and the initiation of one or both reperfusion treatment(s) should therefore be as short as possible. The speed of the process strongly depends on five factors: patient location, regional patient allocation by emergency medical services (EMS), travel times of EMS, treatment locations, and in-hospital delays. Regional patient allocation by EMS and treatment locations are sub-optimally configured in daily practice. Our aim is to construct a mathematical model for the joint decision of treatment locations and allocation of acute stroke patients in a region, such that the time until treatment is minimized. We describe acute stroke care as a multi-flow two-level hierarchical facility location problem and the model is formulated as a mixed integer linear program. The objective of the model is the minimization of the total time until treatment in a region and it incorporates volume-dependent in-hospital delays. The resulting model is used to gain insight in the performance of practically oriented patient allocation protocols, used by EMS. We observe that the protocol of directly driving to the nearest stroke centre with special facilities (i.e., the mothership protocol) performs closest to optimal, with an average total time delay that is 3.9% above optimal. Driving to the nearest regional stroke centre (i.e., the drip-and-ship protocol) is on average 8.6% worse than optimal. However, drip-and-ship performs better than the mothership protocol in rural areas and when a small fraction of the population (at most 30%) requires the second procedure, assuming sufficient patient volumes per stroke centre. In the experiments, the time until treatment using the optimal model is reduced by at most 18.9 minutes per treated patient. In economical terms, assuming 150 interventional procedures per year, the value of medical intervention in acute stroke can be improved upon up to € 1,800,000 per year.

Intrinsic hospital factors: overlooked cause for variations in delay to transfer for endovascular thrombectomy

BACKGROUND

Intrinsic hospital factors leading to time delay to inter-hospital transfer for endovascular thrombectomy (EVT) have not been adequately investigated, leading to uncertainty in generalizability of hub and spoke EVT services. We investigated the contribution of intrinsic hospital factors to variations in time delay in a multicenter, retrospective study.

METHODS

The setting was a hub and spoke EVT state-wide system for a population of 6.3 million and 34 spoke hospitals. We collected data on acute large vessel occlusion strokes transferred from spoke to hub for consideration of EVT between January 2016 and December 2018. The primary endpoint was the proportion of variability in delay-time in transfer cases contributed to by intrinsic hospital factors estimated through variance component analysis implemented as a mixed-effect linear regression model with hospitals as random effects.

RESULTS

We included 434 patients. The median age was 72 years (IQR 62-79), 44% were female, and the median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 11-20). The median onset to CT time was 100 mins (IQR 69-157) at the spoke hospitals and CT acquisition at the spoke hospital to time of transfer was 93 min (IQR 70-132). 53% of the observed variability in time from CT acquisition at the spoke hospital to transfer to the EVT center was explained by intrinsic hospital factors, as opposed to patient-related factors.

CONCLUSIONS

Intrinsic hospital factors explained more than half of the observed variability in time from CT acquisition at the spoke hospital to departure for transfer. We recommend that the design of hub and spoke EVT services should account for intrinsic hospital factors to minimize hospital transfer delay.

Breaking the breach in Latin America: A pilot study of mechanical thrombectomy in the public healthcare system in Chile

BACKGROUND

Mechanical Thrombectomy (MT) is the standard of care for treatment of large vessel occlusion stroke. Until the beginning of 2020 MT was not funded nor widely implemented at the public healthcare level in Chile.

OBJECTIVE

To describe the results of a pilot program created to provide access to public MT in Santiago - Chile.

METHODS

Analysis from a prospectively collected database of MT cases performed between September 2017 and September 2019 in one center. A stroke network was developed with a single MT capable stroke center and five primary stroke centers. The primary efficacy endpoint was the rate of functional independence (mRS 0-2) at 90 days. Successful reperfusion was defined as 2 b-3 according to the thrombolysis in cerebral infarction scale. Safety outcomes include the rates of symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS

A total of 100 patients were treated over the study period. Their mean age was 62.8 ± 11.8 years and median baseline National Institute of Health Stroke Scale (NIHSS) measurement was 17. Seventy-seven percent of the patients received intra venous thrombolysis. Successful reperfusion was achieved in 95% of the cases. NIHSS at 24 hours showed a median drop of 7 points from baseline (p < 0.00001) and 50% of the follow-up patients were functionally independent at 90 days. Symptomatic Intracerebral hemorrhage occurred in 5% of the patients and 90-day all case mortality was 11%.

CONCLUSIONS

We demonstrated the feasibility of a publicly funded MT program in Chile, with similar results as other international randomized control trials.

In-hospital acute stroke workflow in acute stroke - Systems-based approaches

Clinical outcomes of acute ischaemic stroke patients have significantly improved with the advent of reperfusion therapy. However, time continues to be a critical factor. Reducing treatment delays by improving workflows can improve the efficacy of acute reperfusion therapy. Systems-based approaches have improved in-hospital temporal parameters, maximizing the utility of reperfusion therapies and improving clinical benefit to patients. However, studies aimed at optimizing and hence reducing treatment delays in emergency department (ED) settings are limited. The aim of this article is to discuss existing systems-based approaches to optimize ED acute stroke workflows and its value in reducing treatment delays and identify gaps in existing workflows that need optimization. Identifying gaps in acute stroke workflow, variations in processes and challenges in implementation, in the in-hospital settings, is essential for systems-based interventions to be effective in delivering improved outcomes for patients with acute ischaemic stroke.

Outcomes and Issues of 'Drip and Go' as an Inter-Hospital Cooperation System in Mechanical Thrombectomy for Acute Ischemic Stroke

Objective

Mechanical thrombectomy in acute ischemic stroke (AIS) has become popular in recent years. Our affiliated institutes without neuro-endovascular specialists call our department to come to assist and perform thrombectomy (Drip and Go). In this study, the effectiveness of this inter-hospital cooperative system was evaluated.

Methods

Between January 2016 and December 2018, "Drip and Go" was performed in a total of 29 patients (20 males, average age of 75 years) from four hospitals located within a 1-hour drive, that frequently called for AIS assistance. The background and outcomes of such cases were then retrospectively collected and evaluated.

Results

The median National Institutes of Health Stroke Scale (NIHSS) and diffusion-weighed image-Alberta Stroke Programme Early CT Score (DWI-ASPECTS) were 19 and 7, respectively. Gro in puncture was performed in 27 patients (93%) within 6 h of onset. Good reperfusion (thrombolysis in cerebral infarction [TICI] 2b/3) was obtained in 24 patients (82%) with only one patient exhibiting hemorrhagic complication. A total of 12 patients (41%) had a modified Rankin Scale (mRS) score of 0-3 after 90 days or at the time of discharge. Univariate analysis identified a DWI-ASPECTS of 7 or higher as the only significant factor associated with a good neurological prognosis (P <0.05). Neurological prognosis was the most favorable at the furthest hospital where patients had a good DWI-ASPECTS.

Conclusion

By employing a 1-hour arrival time window and proper patient selection, the "Drip and Go" inter-hospital cooperative system can be an alternative approach for covering areas where no neuro-endovascular specialists are available for AIS.

Early Thrombectomy Outcomes in Transfer Patients

OBJECTIVE

The optimal patient transportation destination of acute ischemic stroke (AIS) patients remains uncertain. The purpose of this study was to evaluate the predictive variables that determine stroke outcomes depending on the patient transportation destination.

METHODS

We performed a retrospective study using an AIS database consisting of patients who underwent thrombectomy admitted to our institution from November 1, 2011, through October 1, 2018.

RESULTS

A total of 171 patients were included in the statistical analysis; 42.1% (72/171) of patients were in the mothership group (directly admitted) and 57.9% (99/171) in the drip-and-ship group (transferred). Multivariable logistic regression revealed the predictive factors for favorable outcomes were driving distance (expressed in miles) between the patient's home and a comprehensive stroke center (CSC) (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.90-0.99; P = .035), absence of diabetes mellitus (OR = 3.60; 95% CI, 1.20-10.82; P = .022), lower National Institutes of Health Stroke Scale score at admission (OR = 0.91; 95% CI, 0.85-0.97; P = .003), and shorter symptom onset to CSC arrival time (expressed in hours) (OR = 0.84; 95% CI, 0.72-0.99; P = .038).

CONCLUSIONS

Our study revealed that a shorter driving distance between the patient's home and CSC, absence of diabetes, lower National Institutes of Health Stroke Scale score, and shorter onset to hospital arrival time positively impacted the outcomes of endovascularly treated AIS patients.