Abstract
Background and purposeDirect presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT.MethodsWe used data from the MR CLEAN Registry (2014–2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders.ResultsOf the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p < 0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted β = − 51.6, 95% CI: − 64.0 to − 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted β = − 44.0, 95% CI: − 65.5 to − 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73–2.08).ConclusionsIn patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome.
Highlights
Background and purposeDirect presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT)
We excluded 2957 patients, either because they were treated with IVT (n = 2640), because it was unknown whether they were treated with IVT (n = 74), or because they had an in-hospital stroke (n = 243)
When the increased travel time for transferred patients was taken into account, adjusted onset-to-groin time (OGT) was still 18 min shorter for patients directly presented to a CSC, this was not statistically significant
Summary
Intravenous thrombolysis (IVT) is the standard treatment for patients with acute ischemic stroke (AIS) [1]. Patients who are eligible for EVT are subsequently transferred to a comprehensive stroke center (CSC) Studies show that this ‘dripand-ship’ system delays initiation of EVT by 40–106 min and decreases the chance of a good clinical outcome by approximately 10% [3–5]. 20% of patients who undergo EVT in routine practice do not receive IVT because of a contraindication for alteplase [6] Most of these contraindications, such as anticoagulation use and duration of symptoms > 4.5 h, can be determined in the ambulance. For patients with such a contraindication for IVT, no valuable time would be lost by bypassing the PSC and going directly to a CSC. We analyzed workflow times and clinical outcomes after EVT in patients who were not eligible for IVT, and compared these outcomes between patients who were directly presented to a CSC to those initially presented to a PSC
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