Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

Ovid Technologies (Wolters Kluwer Health) - Tập 136 Số 24 - Trang 2311-2321 - 2017
Michael T. Froehler1, Jeffrey L. Saver2, Marc Ribó3, Reza Jahan2, Mohammad Ali Aziz‐Sultan4, Richard Klucznik5, Diogo C Haussen6, Frank R Hellinger7, Dileep R. Yavagal8, Tom L. Yao9, David S Liebeskind2, Ashutosh P. Jadhav10, Rishi Gupta11, Ameer E Hassan12, Coleman Martin13, Hormozd Bozorgchami14, Ritesh Kaushal15, Raul G Nogueira6, Ravi H. Gandhi7, Eric C. Peterson8, Shervin R. Dashti9, Curtis A. Given16, Brijesh Mehta17, Vivek R. Deshmukh18, Sidney Starkman2, Italo Linfante19, Scott H. McPherson20, Peter Kvamme21, Thomas Grobelny22, Muhammad Shazam Hussain23, Ike Thacker24, Nirav Vora25, Peng Roc Chen26, Stephen J. Monteith27, Robert D. Ecker28, Clemens M. Schirmer29, Eric Sauvageau30, Alex Abou‐Chebl31, Colin P. Derdeyn32, Lucian Maidan33, Aamir Badruddin34, Adnan H. Siddiqui35, Travis M. Dumont36, Abdulnasser Alhajeri37, Muhammad Taqi38, Khaled Asi39, Jeffrey Carpenter40, Alan S. Boulos41, Gaurav Jindal42, Ajit S Puri43, Rohan Chitale44, Eric M. Deshaies45, David Robinson46, David F. Kallmes47, Blaise Baxter48, Mouhammad Jumaa49, Peter Sunenshine50, Aniel Majjhoo51, Joey English52, Shuichi Suzuki53, Richard D. Fessler54, Josser E Delgado Almandoz55, Jerry C. Martin, Nils Mueller‐Kronast15
1Cerebrovascular Program, Vanderbilt University Medical Center, A0118 Med Center North, Nashville, TN 37232.
2University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.).
3St Vincent Mercy Hospital, Toledo, OH (O.O.Z.).
4Brigham and Women’s Hospital, Boston, MA (M.A.A.-S.).
5Methodist Hospital, Houston, TX (R.P.K.).
6Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.).
7Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.).
8University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.).
9Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.).
10University of Pittsburgh Medical Center, PA (A.P.J.).
11WellStar Neurosciences Network, WellStar Kennestone Regional Medical Center, Marietta, GA (R.G.).
12Valley Baptist Medical Center, Harlingen, TX (A.E.H.).
13St. Luke’s Hospital of Kansas City, MO (C.O.M.).
14Oregon Health and Science University Hospital, Portland (H.B.).
15Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., N.H.M.-K.).
16Baptist Health Lexington/Central Baptist, KY (C.A.G.).
17South Broward Hospital, Hollywood, FL (B.P.M.).
18Providence St Vincent Medical Center, Portland, OR (V.D.).
19Baptist Hospital of Miami, FL (I.L.).
20St Dominic’s-Jackson Memorial Hospital, MS (S.H.M.).
21University of Tennessee Medical Center, Knoxville (P.K.).
22Advocate Christ Medical Center, Oak Lawn, IL (T.J.G.).
23Cleveland Clinic, OH (M.S.H.).
24Baylor University Medical Center, Dallas, TX (I.T.).
25OhioHealth Riverside Methodist Hospital, Columbus (N.V.).
26Memorial Hermann Texas Medical Center, Houston (P.R.C.).
27Swedish Medical Center First Hill Campus, Seattle, WA (S.J.M.).
28Maine Medical Center, Portland (R.D.E.).
29Geisinger Clinic, Danville, PA (C.M.S.).
30Baptist Medical Center–Jacksonville, FL (E.S.).
31Baptist Hospital Louisville, KY (A.A.-C.).
32Barnes Jewish Hospital, St Louis, MO (C.P.D.).
33Mercy San Juan Medical Center and Mercy General, Carmichael, CA (L.M.).
34Presence St Joseph Medical Center, Joliet, IL (A.B.).
35Buffalo General Medical Center, NY (A.H.S.).
36University of Arizona Medical Center, Tucson (T.M.D.).
37University of Kentucky Hospital, Lexington (A.A.).
38Los Robles Medical Center, Thousand Oaks, CA (M.A.T.).
39Aurora Hospital, Milwaukee, WI (K.A.).
40West Virginia University/Ruby Memorial Hospital, Morgantown (J.C.).
41Albany Medical Center, NY (A.B.).
42University of Maryland Medical Center, Baltimore (G.J.).
43University of Massachusetts Memorial Medical Center, Worcester (A.S.P.).
44Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.).
45Crouse Hospital, Syracuse, NY (E.M.D.).
46Virginia Mason Medical Center, Seattle, WA (D.H.R.).
47Mayo Clinic–Rochester, MN (D.F.K.).
48Erlanger Medical Center, Chattanooga, TN (B.W.B.).
49ProMedica Toledo Hospital, OH (M.A.J.).
50Banner University Medical Center, Phoenix, AZ (P.S.).
51McLaren Flint, MI (A.M.).
52California Pacific Medical Center, San Francisco, CA (J.D.E.).
53University of California, Irvine, Orange (S.S.).
54St John Providence Hosptial, Detroit, MI (R.D.F.).
55Abbott Northwestern Hospital, Minneapolis, MN (J.E.D.A.). Carolinas Medical Center, Charlotte, NC.

Tóm tắt

Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( P <0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P =0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P =0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P =0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.

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Ovid Technologies (Wolters Kluwer Health)

Tập 136 Số 24

2311-2321

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