Abstract 3168: “Drip-and-Ship” Thrombolysis Combined with Intra-Arterial Therapy for Acute Ischemic Stroke: a Single Center Experience

Abstract

Introduction: A subset of patients with acute ischemic stroke (AIS) who are treated with intravenous tissue plasminogen activator (IV tPA) may benefit from further intra-arterial (IA) treatment but are initially treated at hospitals without endovascular resources. This necessitates emergent transfer (“drip-and-ship” strategy) to a facility with IA capabilities. The safety and utility of this method has not been sufficiently evaluated. Hypothesis: We assessed the hypothesis that the “drip-and-ship” strategy can be safely combined with IA therapy and leads to improved outcomes following acute ischemic stroke. Methods: We retrospectively reviewed consecutive AIS patients from July 2007 to May 2011 who were treated with IV tPA at community hospitals and then emergently transferred to our comprehensive stroke center. Demographic, clinical, and radiographic data were retrieved from an electronic registry. National Institutes of Health Stroke Scale scores were abstracted from the medical records prior to tPA administration and at hospital discharge (amongst survivors). Protocol violations and treatment-related complications were abstracted from the medical record. Results: Among 65 “drip-and-ship” IV tPA patients (mean age 62 years, 57% male) admitted to our stroke center, the median NIHSS score was 16 and median onset-to-treatment time was 160 (IQR 125-193) minutes; 72% were treated in the 3-hour window. There were 8 (12.3%) protocol violations: 1 treated > 4.5 hours from onset, 1 treated with cardiac dose of tPA, 1 treated in 3-4.5hr window despite NIHSS score > 25, 2 despite prior stroke and diabetes history, and 3 despite age > 80 years. Twenty-five patients (38%) underwent subsequent IA therapy. Overall, there were 12 (18.5%) intracranial hemorrhages (IV-9.8%, IV + IA-33.3%, p=0.024), of which 3 (4.6%) were sICH (IV-2.4%, IV + IA-8.3%; p=0.274). In-hospital mortality was higher among IV-IA patients (16.7 vs. 4.9%, p=0.183) than IV tPA alone. Among survivors (n=59), the median NIHSS improved from admission to discharge for IV tPA alone (13 to 6, p < 0.001) and following IV-IA treatment (20 to 13, p < 0.001). Conclusions: “Drip-and-ship” thrombolysis appears safe despite an increase in protocol violations. A combined approach with IA treatment leads to improvements in the NIHSS score at discharge and has a safety profile comparable to previous studies. A combined “drip-and-ship” model for acute ischemic stroke may be a safe and effective strategy to increase access to IA therapy among eligible patients presenting to community hospitals with large artery occlusion.