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Seners P, Wouters A, Ter Schiphorst A, Yuen N, Mlynash M, Arquizan C, Heit JJ, Kemp S, Christensen S, Sablot D, Wacongne A, Lalu T, Costalat V, Lansberg MG, Albers GW. Arterial Recanalization During Interhospital Transfer for Thrombectomy. Stroke 2024; 55:1525-1534. [PMID: 38752736 PMCID: PMC11338625 DOI: 10.1161/strokeaha.124.046694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Patients with acute ischemic stroke harboring a large vessel occlusion admitted to nonendovascular-capable centers often require interhospital transfer for thrombectomy. We evaluated the incidence and predictors of arterial recanalization during transfer, as well as the relationship between interhospital recanalization and clinical outcomes. METHODS We analyzed data from 2 cohorts of patients with an anterior circulation large vessel occlusion transferred for consideration of thrombectomy to a comprehensive center, with arterial imaging at the referring hospital and on comprehensive stroke center arrival. Interhospital recanalization was determined by comparison of the baseline and posttransfer arterial imaging and was defined as revised arterial occlusive lesion (rAOL) score 2b to 3. Pretransfer variables independently associated with interhospital recanalization were studied using multivariable logistic regression analysis. RESULTS Of the 520 included patients (Montpellier, France, n=237; Stanford, United States, n=283), 111 (21%) experienced interhospital recanalization (partial [rAOL=2b] in 77% and complete [rAOL=3] in 23%). Pretransfer variables independently associated with recanalization were intravenous thrombolysis (adjusted odds ratio, 6.8 [95% CI, 4.0-11.6]), more distal occlusions (intracranial carotid occlusion as reference: adjusted odds ratio, 2.0 [95% CI, 0.9-4.5] for proximal first segment of the middle cerebral artery, 5.1 [95% CI, 2.3-11.5] for distal first segment of the middle cerebral artery, and 5.0 [95% CI, 2.1-11.8] for second segment of the middle cerebral artery), and smaller clot burden (clot burden score 0-4 as reference: adjusted odds ratio, 3.4 [95% CI, 1.5-7.6] for 5-7 and 5.6 [95% CI, 2.4-12.7] for 8-9). Recanalization on arrival at the comprehensive center was associated with less interhospital infarct growth (rAOL, 0-2a: 11.6 mL; rAOL, 2b: 2.2 mL; rAOL, 3: 0.6 mL; Ptrend<0.001) and greater interhospital National Institutes of Health Stroke Scale score improvement (0 versus -5 versus -6; Ptrend<0.001). Interhospital recanalization was associated with reduced 3-month disability (adjusted common odds ratio, 2.51 [95% CI, 1.68-3.77]) with greater benefit from complete than partial recanalization. CONCLUSIONS Recanalization is frequently observed during interhospital transfer for thrombectomy and is strongly associated with favorable outcomes, even when partial. Broadening thrombolysis indications in primary centers, and developing therapies that increase recanalization during transfer, will likely improve clinical outcomes.
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Affiliation(s)
- Pierre Seners
- Stanford Stroke Center, Palo Alto, CA
- Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), U1266, INSERM, Paris
| | - Anke Wouters
- Stanford Stroke Center, Palo Alto, CA
- Department of Neurosciences Division of Experimental Neurology, KU Leuven, Leuven, Belgium
| | | | | | | | - Caroline Arquizan
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), U1266, INSERM, Paris
- Neurology Department, CHRU Gui de Chauliac, Montpellier, France
| | - Jeremy J. Heit
- Radiology Department, Stanford University, Palo Alto, CA
| | | | | | | | | | | | - Vincent Costalat
- Neuroradiology Department, CHRU Gui de Chauliac, Montpellier, France
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Mbonde A, Young MJ, Dmytriw AA, Moyer QJ, Hirsch JA, Leslie-Mazwi TM, Rost NS, Patel AB, Regenhardt RW. Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities. J Neurol 2024; 271:188-197. [PMID: 37815578 DOI: 10.1007/s00415-023-12028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
IMPORTANCE Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process. OBSERVATIONS IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base. CONCLUSIONS AND RELEVANCE This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.
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Affiliation(s)
- Amir Mbonde
- Harvard Medical School, Boston, MA, USA.
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | | | - Adam A Dmytriw
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Quentin J Moyer
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Robert W Regenhardt
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Morsi RZ, Zhang Y, Zhu M, Xie S, Carrión-Penagos J, Desai H, Tannous E, Kothari SA, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Siegler JE, Coleman ER, Mendelson SJ, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis. Neuroepidemiology 2023; 58:47-56. [PMID: 38128500 PMCID: PMC10857025 DOI: 10.1159/000535796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone. METHODS We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio. RESULTS The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons. CONCLUSION Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA,
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Meng Zhu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shitong Xie
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin A Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- DENT Neuroimaging Center, DENT Neurologic Institute, Amherst, New York, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James E Siegler
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | | | - Scott J Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Micieli G, Cortelli P, Del Sette M, Cavallini A, Zanferrari C, De Falco A, Quatrale R, Maria G, Cossu G, Haggiag S, Pezzella FR, Zedde ML, Rea F. The Italian hub-and-spoke network for the emergency neurology management. Neurol Sci 2023; 44:3929-3937. [PMID: 37326936 DOI: 10.1007/s10072-023-06883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim of the present study was to assess emergency neurology management in Italy by comparing patients admitted to the hub and spoke hospitals. METHODS Data obtained from the annual Italian national survey (NEUDay) investigating the activity and facilities of neurology in the emergency room conducted in November 2021 were considered. Information for each patient who received a neurologic consultation after accessing the emergency room was acquired. Data on facilities were also gathered, including hospital classification (hub vs spoke), number of consultations, presence of neurology and stroke unit, number of beds, availability of neurologist, radiologist, neuroradiologist, and instrumental diagnostic accessibility. RESULTS Overall, 1,111 patients were admitted to the emergency room and had neurological consultation across 153 facilities (out of the 260 Italian ones). Hub hospitals had significantly more beds, availability of neurological staff, and instrumental diagnostic accessibility. Patients admitted to hub hospital had a greater need for assistance (higher number of yellow/red codes at neurologist triage). A higher propensity to be admitted to hub centers for cerebrovascular problems and to receive a diagnosis of stroke was observed. CONCLUSIONS The identification of hub and spoke hospitals is strongly characterized by the presence of beds and instrumentation mainly dedicated to acute cerebrovascular pathologies. Moreover, the similarity in the number and type of accesses between hub and spoke hospitals suggests the need to look for adequate identification of all the neurological pathologies requiring urgent treatment.
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Affiliation(s)
- Giuseppe Micieli
- Former Department of Emergency Neurology, IRCCS C. Mondino Foundation, Pavia, Italy.
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche Di Bologna, Bologna, Italy
- DIBINEM, University of Bologna, Bologna, Italy
| | - Massimo Del Sette
- Neurology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Anna Cavallini
- Emergency Neurology and Stroke Unit, IRCCS Fondazione Mondino-IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carla Zanferrari
- Neurology and Stroke Unit, ASST Melegnano-Martesana, Vizzolo Predabissi, Milan, Italy
| | - Arturo De Falco
- Neurology and Stroke Unit, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy
| | - Rocco Quatrale
- Dipartimento di Scienze Neurologiche, UOC di Neurologia-Ospedale dell'Angelo, AULSS 3 Serenissima, Venezia Mestre, Italy
| | - Guarino Maria
- Neurology, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanni Cossu
- SSD Neurophysiology and Movement Disorders, Department of Neuroscience, ARNAS Brotzu, Cagliari, Italy
| | - Shalom Haggiag
- Dipartimento di Neuroscienze, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | | | - Maria Luisa Zedde
- Neurology and Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Federico Rea
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Laboratory of Healthcare Research & Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
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