Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Clinical Trial
. 2017 Dec 12;136(24):2311-2321.
doi: 10.1161/CIRCULATIONAHA.117.028920. Epub 2017 Sep 24.

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)

Michael T Froehler  1 , Jeffrey L Saver  2 , Osama O Zaidat  3 , Reza Jahan  2 , Mohammad Ali Aziz-Sultan  4 , Richard P Klucznik  5 , Diogo C Haussen  6 , Frank R Hellinger Jr  7 , Dileep R Yavagal  8 , Tom L Yao  9 , David S Liebeskind  2 , Ashutosh P Jadhav  10 , Rishi Gupta  11 , Ameer E Hassan  12 , Coleman O Martin  13 , Hormozd Bozorgchami  14 , Ritesh Kaushal  15 , Raul G Nogueira  6 , Ravi H Gandhi  7 , Eric C Peterson  8 , Shervin R Dashti  9 , Curtis A Given 2nd  16 , Brijesh P Mehta  17 , Vivek Deshmukh  18 , Sidney Starkman  2 , Italo Linfante  19 , Scott H McPherson  20 , Peter Kvamme  21 , Thomas J Grobelny  22 , Muhammad S Hussain  23 , Ike Thacker  24 , Nirav Vora  25 , Peng Roc Chen  26 , Stephen J Monteith  27 , Robert D Ecker  28 , Clemens M Schirmer  29 , Eric Sauvageau  30 , Alex Abou-Chebl  31 , Colin P Derdeyn  32 , Lucian Maidan  33 , Aamir Badruddin  34 , Adnan H Siddiqui  35 , Travis M Dumont  36 , Abdulnasser Alhajeri  37 , M Asif Taqi  38 , Khaled Asi  39 , Jeffrey Carpenter  40 , Alan Boulos  41 , Gaurav Jindal  42 , Ajit S Puri  43 , Rohan Chitale  44 , Eric M Deshaies  45 , David H Robinson  46 , David F Kallmes  47 , Blaise W Baxter  48 , Mouhammad A Jumaa  49 , Peter Sunenshine  50 , Aniel Majjhoo  51 , Joey D English  52 , Shuichi Suzuki  53 , Richard D Fessler  54 , Josser E Delgado Almandoz  55 , Jerry C Martin, Nils H Mueller-Kronast  15 ; STRATIS Investigators
Affiliations
Clinical Trial

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)

Michael T Froehler et al. Circulation. .

Abstract

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.

Keywords: emergency medical services; endovascular treatment; ischemic stroke; stent retriever; systems of care.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Median time intervals from stroke onset (the time of last seen well) through revascularization. A, All patients who received IV-tPA before MT. There is a significant difference in onset-to-revascularization times (blue line). B, All patients who underwent MT alone (no IV-tPA). There is a significant difference in onset-to-revascularization times (blue line). EMS indicates emergency medical services; IV-tPA, intravenous tissue plasminogen activator; and MT, mechanical thrombectomy.
Figure 2.
Figure 2.
Unadjusted clinical outcomes at 90 days based on mRS, presented as percentage of the total. A, All patients, divided by direct admission (top) vs. interhospital transfer (bottom). There is a significant difference between the 2 groups by shift analysis (P=0.012 by Cochran-Mantel-Haenszel test). B, Comparison of outcomes based on mRS between direct and transfer divided into patients who received IV-tPA before MT (top) and those who underwent MT alone (bottom). Shift analysis revealed a significant difference between transfer and direct groups for MT alone (P=0.035) and a nonsignificant trend for IV-tPA (P=0.14). IV-tPA indicates intravenous tissue plasminogen activator; mRS, modified Rankin Scale; and MT, mechanical thrombectomy.
Figure 3.
Figure 3.
Relationship between rate of functional independence (mRS 0–2 at 90 days) and time from onset to puncture for direct (blue) vs. transfer (red) patients. The logistic curves have been truncated at the 95% distribution for each group, and thus the transfer group is shifted to the right (later average treatment time) compared with the direct group. Shading represents the 95% confidence interval for each group. The slopes do not differ between the 2 groups (P=0.35), suggesting that differences in outcome are related only to time. The rate of functional independence decreased by 5.5% per hour for all patients. mRS indicates modified Rankin Scale.
See this image and copyright information in PMC

Comment in

Similar articles

  • Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke: Primary Results of the STRATIS Registry.
    Mueller-Kronast NH, Zaidat OO, Froehler MT, Jahan R, Aziz-Sultan MA, Klucznik RP, Saver JL, Hellinger FR Jr, Yavagal DR, Yao TL, Liebeskind DS, Jadhav AP, Gupta R, Hassan AE, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti SR, Given CA 2nd, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Abou-Chebl A, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson DH, Kallmes DF, Baxter BW, Jumaa MA, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado Almandoz JE, Martin JC, Haussen DC; STRATIS Investigators. Mueller-Kronast NH, et al. Stroke. 2017 Oct;48(10):2760-2768. doi: 10.1161/STROKEAHA.117.016456. Epub 2017 Aug 22. Stroke. 2017. PMID: 28830971
  • Impact of Stent Retriever Size on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry.
    Zaidat OO, Haussen DC, Hassan AE, Jadhav AP, Mehta BP, Mokin M, Mueller-Kronast NH, Froehler MT. Zaidat OO, et al. Stroke. 2019 Feb;50(2):441-447. doi: 10.1161/STROKEAHA.118.022987. Stroke. 2019. PMID: 30626287 Clinical Trial.
  • Impact of Balloon Guide Catheter Use on Clinical and Angiographic Outcomes in the STRATIS Stroke Thrombectomy Registry.
    Zaidat OO, Mueller-Kronast NH, Hassan AE, Haussen DC, Jadhav AP, Froehler MT, Jahan R, Ali Aziz-Sultan M, Klucznik RP, Saver JL, Hellinger FR Jr, Yavagal DR, Yao TL, Gupta R, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti S, Given CA 2nd, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Chebl AB, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson D, Kallmes DF, Baxter BW, Jumaa M, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado-Almandoz J, Martin JC, Liebeskind DS; STRATIS Investigators. Zaidat OO, et al. Stroke. 2019 Mar;50(3):697-704. doi: 10.1161/STROKEAHA.118.021126. Stroke. 2019. PMID: 30776994
  • Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis.
    MacKenzie IER, Arusoo T, Sigounas D. MacKenzie IER, et al. World Neurosurg. 2021 Aug;152:e387-e397. doi: 10.1016/j.wneu.2021.05.106. Epub 2021 Jun 1. World Neurosurg. 2021. PMID: 34087463
  • Endovascular Treatment of Acute Ischemic Stroke.
    Silva GS, Nogueira RG. Silva GS, et al. Continuum (Minneap Minn). 2020 Apr;26(2):310-331. doi: 10.1212/CON.0000000000000852. Continuum (Minneap Minn). 2020. PMID: 32224754 Review.
See all similar articles

Cited by

See all "Cited by" articles

References

    1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, III, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB Writing Group Members; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation. 2016;133:e38–e360. doi: 10.1161/CIR.0000000000000350. - PubMed
    1. Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, Barker-Collo S, Moran AE, Sacco RL, Truelsen T, Davis S, Pandian JD, Naghavi M, Forouzanfar MH, Nguyen G, Johnson CO, Vos T, Meretoja A, Murray CJ, Roth GA GBD 2013 Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology. 2015;45:161–176. doi: 10.1159/000441085. - PMC - PubMed
    1. Smith WS, Tsao JW, Billings ME, Johnston SC, Hemphill JC, 3rd, Bonovich DC, Dillon WP. Prognostic significance of angiographically confirmed large vessel intracranial occlusion in patients presenting with acute brain ischemia. Neurocrit Care. 2006;4:14–17. - PubMed
    1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. doi: 10.1056/NEJMoa1411587. - PubMed
    1. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–1018. doi: 10.1056/NEJMoa1414792. - PubMed

Associated data