Frequency and Timing of Endovascular Therapy in Acute Stroke Patients: A Population-Based Analysis Using the Bremen Stroke Register

Optimized density and locations of stroke centers for improved cost effectiveness of mechanical thrombectomy in patients with acute ischemic stroke

BACKGROUND

Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs).

METHODS

This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis.

RESULTS

The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained.

CONCLUSION

The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.

Effectiveness and safety of mechanical thrombectomy for acute ischaemic stroke in Latin American countries: A systematic review

OBJECTIVE

To describe the use, effectiveness, and safety outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in Latin American countries.

MATERIALS AND METHODS

Studies reporting MT outcomes for AIS in Latin America were identified in CINAHL, MEDLINE, Web of Science, SciELO, EMBASE, and LILACS databases. Synthesis was conducted according to effectiveness (recanalization rates) and safety measures (mortality and functional independence at 90 days).

RESULTS

Seventeen studies were included, mainly from public and university hospitals. MT utilization varied from 2.6% to 50.1%, while successful recanalization ranged from 63% to 95%. Functional independence 90 days after stroke (a modified Rankin scale score of 0 to 2) was achieved in less than 40% across most studies. Mortality rates were below 30%; studies with posterior circulation strokes reported higher mortality rates. The randomized trial reported better health outcomes for functional independence among patients in the MT group (OR 2.28; 95% CI, 1.41 - 3.69), favoring MT over standard care.

CONCLUSIONS

The included studies had great methodological heterogeneity due to differences in study design, the MT time window, and stroke location. The only randomized trial showed improved functional independence and lower mortality rates with MT than with standard care. The rest of the studies reported similar findings to available literature. Efforts to improve stroke care are reflected in improved patient outcomes in the region. Future studies should consider standard time window criteria and reduce the risk of bias by including representative samples and comparison groups.

Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago

STUDY OBJECTIVE

Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers.

METHODS

We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models.

RESULTS

Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]).

CONCLUSION

Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.