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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.

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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

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