Abstract 1122‐000031: Reasons Thrombectomy Candidates Become Ineligible After Transfer for Treatment in a Hub‐And‐Spoke Telestroke Model

Abstract

Introduction : The care of emergent large vessel occlusion (ELVO) stroke patients has been revolutionized by endovascular thrombectomy (EVT). Given its robust efficacy, it is crucial to optimize delivery to eligible patients. Within hub‐and‐spoke hospital system models, some patients first present to distant spoke hospitals and require transfer to hub hospitals for EVT. We sought to understand reasons EVT candidates become ineligible after transfer for treatment. Methods : Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre‐transfer CTA‐defined ELVO and Alberta Stroke Program Early CT Score ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90‐day functional independence (modified Rankin Scale, mRS ≤2). Results : 258 patients were identified with median age 70 years (IQR 60–81) and 50% female. 44% underwent EVT upon hub arrival, of which 87% achieved Thrombolysis in Cerebral Infarction 2b‐3 reperfusion. Compared to EVT‐eligible patients, ineligible patients were older (73 vs 68 years, p = 0.04), had lower NIH Stroke Scale (NIHSS, 10 vs 16, p<0.0001), longer LKW‐hub arrival time (8.4 vs 4.6 hours, p<0.0001), and received less IV alteplase (32% vs 45%, p = 0.04). The clinical reasons cited for becoming EVT ineligible upon hub arrival included large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion location (5%), subocclusive lesion (3%), and goals of care (3%). Becoming EVT ineligible independently reduced the odds of 90‐day functional independence (aOR = 0.26, 95%CI = 0.12,0.56; p = 0.001), even when controlling for age, NIHSS, and LKW‐hub arrival time. Conclusions : Approaches to increase EVT eligibility among ELVO transfers may improve long term outcomes. A primary reason for becoming EVT ineligible is infarct growth. Future studies should explore triaging patients directly to EVT‐capable hubs when feasible, improving inter‐hospital transfer times, supporting ischemic penumbra before EVT, and developing novel neuroprotective agents.