EMS Bypass to Endovascular Stroke Centers is Associated with Shorter Time to Thrombolysis and Thrombectomy for LVO Stroke

Abstract

Objectives Large vessel occlusion (LVO) strokes may be eligible for treatment with intravenous thrombolysis (IVT) and endovascular therapy (EVT). Patients selected for treatment have better neurologic outcomes with EVT, and delays in this therapy lead to worse outcomes. However, EVT is offered at a limited number of hospitals, referred to as endovascular stroke centers (ESC). This poses a difficult decision for EMS: to take potential stroke patients to the closest primary stroke center (PSC) or longer transport time to a more distant ESC. We hypothesized that patients with LVO stroke undergoing EVT transported directly to an ESC would have more favorable outcomes as measured by the modified Rankin scale (mRS) at 90 days, compared to transport to a PSC followed by transfer to an ESC. Methods The OPUS-REACH consortium examined transportation patterns and outcomes in patients with LVO stroke who received endovascular treatment. This cohort includes 2400 patients with LVO stroke throughout eight endovascular centers in the Northeast U.S. from 2015 to 2020. All patients enrolled in the OPUS-REACH database were eligible for inclusion. Patients were excluded if they were missing the pickup address, had an in-hospital stroke, or arrived via mobile stroke unit. The remaining patients were separated into two groups: the bypass group, with transportation by EMS to an ESC by bypassing PSC, and the non-bypass group, with initial transport to PSC and interfacility transport to an ESC. The primary outcome was the modified Rankin scale (mRS) at 90 days, where 0–2 was defined as “good”. Results The primary outcome did not reach significance with 40% of the bypass group as compared with the 33.1% of the non-bypass group having a “good” outcome. However, the bypass group underwent shorter times from last-known-well to both thrombolysis (120.9 vs 153.3 min, p < 0.001) and thrombectomy (356.1 vs 454.8 min, p = 0.001). Conclusions In patients with LVO stroke who undergo thrombectomy, EMS transport directly to an ESC results in shorter time thrombectomy, although we did not observe a difference in 90-day functional outcomes. Additionally, bypass to reach a more capable endovascular stroke center does not delay administration of IVT from time of LKW.