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
. 2020 Nov;12(11):1058-1063.
doi: 10.1136/neurintsurg-2019-015593. Epub 2020 May 8.

Impact of EMS bypass to endovascular capable hospitals: geospatial modeling analysis of the US STRATIS registry

Nils Mueller-Kronast  1 , Michael T Froehler  2 , Reza Jahan  3 , Osama Zaidat  4 , David Liebeskind  5 , Jeffrey L Saver  6 ; STRATIS Investigators
Affiliations

Impact of EMS bypass to endovascular capable hospitals: geospatial modeling analysis of the US STRATIS registry

Nils Mueller-Kronast et al. J Neurointerv Surg. 2020 Nov.

Abstract

Background: Routing patients directly to endovascular capable centers (ECCs) would decrease time to mechanical thrombectomy (MT), but may delay intravenous thrombolysis (IVT).

Objective: To study the clinical outcomes of patients with a stroke transferred directly to ECCs compared with those transferred to ECCs from non-endovascular capable centers (nECCs).

Methods: Data from the STRATIS registry were analyzed to evaluate process and clinical outcomes under five routing policies: (1) transport to nearest nECC; (2) transport to STRATIS ECC over any distance or (3) within 20 miles; (4) transport to ideal ECC (iECC), over any distance or (5) within 20 miles.

Results: Among 236 patients, 117 (49.6%) were transferred by ground, of whom 62 (53%) were transferred within 20 miles. Median MT start time was accelerated in all direct transport models. IVT start was prolonged with direct transport across all distances, but accelerated with direct transport to iECC ≤20 miles. With bypass limited to ≤20 miles, the median modeled EMS arrival to IVT interval decreased for both iECCs and ECCs (by 12 min and 6 min, respectively), and median EMS arrival to puncture time decreased by up to 94 min. In this cohort, no patient would have become ineligible for IVT. Bypass to iECC modeling under 20 miles showed a significant reduction in the level of disability at 3 months, with freedom from disability (modified Rankin Scale score 0-1) at 3 months increased by 12%.

Conclusions: Direct routing of patients with a large vessel occlusion to ECCs, especially when within 20 miles, may lead to better clinical outcomes by accelerating the start of MT without any delay of IVT.

Clinical trial registration number: http://www.clinicaltrials.gov. Unique identifier: NCT02239640.

Keywords: stroke; thrombectomy.

PubMed Disclaimer

Conflict of interest statement

Competing interests: NM-K and OZ serve as scientific consultants regarding trial design and conduct to Medtronic, who sponsored this study. MTF serves as a scientific consultant to Medtronic, Stryker, Balt, Viz.ai, NeurVana, and Genentech, and has received research funding from the National Institutes of Health (NIH), Stryker, Medtronic, Microvention, and Endophys. The University of California, Regents receives funding for Dr Jahan’s services as a scientific consultant regarding trial design and conduct to Medtronic/Covidien; RJ is an employee of the University of California, which holds a patent on retriever devices for stroke. The University of California, Regents receives funding for Dr Saver’s services as a scientific consultant regarding trial design and conduct to Covidien and Stryker; JLS is an employee of the University of California, which holds a patent on retriever devices for stroke. DL serves as an imaging core laboratory consultant for Cerenovus, Genentech, Medtronic, Stryker, and Vesalio.

Figures

Figure 1
Figure 1
Patient selection flowchart. Flowchart shows the process and outcomes of identification of patients eligible for this study, based on whether they were first brought to the non-endovascularcapable center (nECC) and then transferred by ground or air to STRATIS ECC hospitals.
Figure 2
Figure 2
Distribution of modeled mRS outcomes at 3 months. Rows indicate actual outcomes with first ground transport to a nECC and then transfer to an ECC, modeled outcomes with first transport direct to STRATIS ECC, and modeled outcomes with first transport direct to an iECC. (A) Among the 236 patients transferred with no limitation of transfer distance. (B) Among the 62 patients transferred by ground within 20 miles of the stroke scene to an ECC (cOR 1.67 (95% CI 1.04 to 2.68]; two-sided shift test, p=0.034). ECC, endovascular capable center; iECC, ideal endovascular capable center; mRS, modified Rankin Scale; nECC, non-endovascular capable center
See this image and copyright information in PMC

References

    1. Goyal M, Menon BK, van Zwam WH, et al. . Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723–31. 10.1016/S0140-6736(16)00163-X - DOI - PubMed
    1. Nogueira RG, Jadhav AP, Haussen DC, et al. . Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018;378:11–21. 10.1056/NEJMoa1706442 - DOI - PubMed
    1. Mueller-Kronast NH, Zaidat OO, Froehler MT, et al. . Systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke: primary results of the STRATIS registry. Stroke 2017;48:2760–8. 10.1161/STROKEAHA.117.016456 - DOI - PubMed
    1. Saver JL, Goyal M, van der Lugt A, et al. . Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016;316:1279–88. 10.1001/jama.2016.13647 - DOI - PubMed
    1. Emberson J, Lees KR, Lyden P, et al. . Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384:1929–35. 10.1016/S0140-6736(14)60584-5 - DOI - PMC - PubMed

MeSH terms

Associated data