In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes

Impact and determinants of door in-door out time for stroke thrombectomy transfers in a large hub-and-spoke network

INTRODUCTION

The mantra "time is brain" cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in-door out (DIDO) times for patients transferred to our hub center for EVT.

METHODS

Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO.

RESULTS

We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57-80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97-149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS (B = 0.007, 95% CI = 0.001-0.012, p = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B = 0.918, 95% CI = 0.010-1.826, p = 0.048), atrial fibrillation or heart failure (B = 0.793, 95% CI = 0.257-1.329, p = 0.004), and basilar LVO location (B = 2.528, 95% CI = 1.154-3.901, p < 0.001).

CONCLUSION

Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes.

Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities

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.

The Italian hub-and-spoke network for the emergency neurology management

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.

Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging

There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.

Percent Insular Ribbon Infarction for Predicting Infarct Growth Rate and 90-Day Outcomes in Large-Vessel Occlusive Stroke: Secondary Analysis of Prospective Clinical Trial Data

Background: Insight into the natural history of infarct growth could help identify patients with slowly progressing stroke who may benefit from delayed endovascular thrombectomy (EVT). Objective: To evaluate associations of percent insular ribbon infarction (PIRI) with infarct growth rate (IGR) and 90-day outcomes in patients with large-vessel occlusion (LVO) stroke. Methods: This retrospective study was a secondary analysis of a prior clinical trial that enrolled patients with acute stroke not treated with reperfusion therapies from January 2007 to June 2009. The present analysis evaluated 31 trial patients (median age, 71 years; 12 female, 19 male) with anterior-circulation LVO who underwent serial MRI examinations. Two neuroradiologists independently scored PIRI on presentation MRI examinations based on the ratio of the length of the portion of the insula showing restricted diffusion to the insula's total length using a previously described 0-4 scale; scores were categorized [mild (0-1), moderate (2), or severe (3-4)], and discrepancies were resolved by consensus. Ninety-day modified Rankin Scale (mRS) was obtained. As part of earlier clinical trial analysis, collateral pattern on CTA was classified (symmetric, malignant, other), and infarct volumes were measured on DWI during the initial 48 hours after presentation and on FLAIR at 90 days. Results: Inter-rater agreement for PIRI category was strong (K=0.890). PIRI was mild in 10, moderate in 4, and severe in 17 patients. For mild, moderate, and severe PIRI, median onset-to-presentation IGR was 1.6, 8.5, and 17.5 cc/h (p<.001); median presentation-to-48-hour IGR was 0.3, 0.2, and 1.2 cc/h (p=.005); median 90-day infarct volume was 9.4, 39.8, and 108.6 cc (p=0.01); 90-day mRS ≤2 occurred in 78%, 67%, and 6% of patients (p=.001). In multivariable models controlling for age, ICA occlusion, and collateral pattern, PIRI category independently predicted onset-to-presentation IGR (β=1.5), presentation-to-48-hour IGR (β=1.3), and 90-day mRS ≤2 (OR=0.2). For predicting 90-day mRS ≤2, mild-to-moderate PIRI had sensitivity of 90.0% and specificity of 84.2%; symmetric collateral pattern had sensitivity of 70.0% and specificity of 73.7%. Conclusion: PIRI was independently associated with IGR and 90-day outcome. Clinical Impact: PIRI may help identify patients who could benefit from late-window EVT when requiring transfer to EVT-capable centers.

Direct to angio-suite large vessel occlusion transfers achieve faster arrival-to-puncture times and improved outcomes

Introduction

For patients with large vessel occlusion (LVO) stroke, time to treatment with endovascular thrombectomy (EVT) is crucial to prevent infarction and improve outcomes. We sought to evaluate the hub arrival-to-puncture times and outcomes for transferred patients accepted directly to the angio-suite (LVO2OR) versus those accepted through the emergency department (ED) in a hub-and-spoke telestroke network.

Methods

Consecutive patients transferred for EVT with spoke CTA-confirmed LVO, spoke ASPECTS >6, and LKW-to-hub arrival <6 hours were identified. Our LVO2OR protocol began implementation in January 2017. The LVO2OR cohort includes patients who underwent EVT from July 2017 to October 2020; the ED cohort includes those from January 2011 to December 2016. Hub arrival-to-puncture time and 90-day modified Rankin Scale (mRS) were prospectively recorded.

Results

The LVO2OR cohort was comprised of 91 patients and the ED cohort 90. LVO2OR patients had more atrial fibrillation (AF, 51% vs 32%, p=0.02) and more M2 occlusions (27% vs 10%, p=0.01). LVO2OR patients had faster median hub arrival-to-puncture time (11 vs 92 minutes, p<0.001), faster median telestroke consult-to-puncture time (2.4 vs 3.6 hours, p<0.001), greater TICI 2b-3 reperfusion (92% vs 69%, p<0.001), and greater 90-day mRS <2 (35% vs 21%, p=0.04). In a multivariable model, LVO2OR significantly increased the odds of 90-day mRS <2 (aOR 2.77, 95%CI 1.07,7.20; p=0.04) even when controlling for age, baseline mRS, AF, NIHSS, M2 location, and TICI 2b-3.

Conclusion

In a hub-and-spoke telestroke network, accepting transferred patients directly to the angio-suite was associated with dramatically reduced hub arrival-to-puncture time and may lead to improved 90-day outcomes. Direct-to-angio-suite protocols should continue to be evaluated in other regions and telestroke models.

Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network

Background

Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility.

Methods

Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2.

Results

Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time.

Conclusions

Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.