Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke

Influence of vascular imaging acquisition at local stroke centers on workflows in the drip-n-ship model: a RACECAT post hoc analysis

BACKGROUND

The influence of vascular imaging acquisition on workflows at local stroke centers (LSCs) not capable of performing thrombectomy in patients with a suspected large vessel occlusion (LVO) stroke remains uncertain. We analyzed the impact of performing vascular imaging (VI+) or not (VI- at LSC arrival on variables related to workflows using data from the RACECAT Trial.

OBJECTIVE

To compare workflows at the LSC among patients enrolled in the RACECAT Trial with or without VI acquisition.

METHODS

We included patients with a diagnosis of ischemic stroke who were enrolled in the RACECAT Trial, a cluster-randomized trial that compared drip-n-ship versus mothership triage paradigms in patients with suspected acute LVO stroke allocated at the LSC. Outcome measures included time metrics related to workflows and the rate of interhospital transfers and thrombectomy among transferred patients.

RESULTS

Among 467 patients allocated to a LSC, vascular imaging was acquired in 277 patients (59%), of whom 198 (71%) had a LVO. As compared with patients without vascular imaging, patients in the VI+ group were transferred less frequently as thrombectomy candidates to a thrombectomy-capable center (58% vs 74%, P=0.004), without significant differences in door-indoor-out time at the LSC (median minutes, VI+ 78 (IQR 69-96) vs VI- 76 (IQR 59-98), P=0.6). Among transferred patients, the VI+ group had higher rate of thrombectomy (69% vs 55%, P=0.016) and shorter door to puncture time (median minutes, VI+ 41 (IQR 26-53) vs VI- 54 (IQR 40-70), P<0.001).

CONCLUSION

Among patients with a suspected LVO stroke initially evaluated at a LSC, vascular imaging acquisition might improve workflow times at thrombectomy-capable centers and reduce the rate of futile interhospital transfers. These results deserve further evaluation and should be replicated in other settings and geographies.

Interhospital transfer of pediatric patients with malignant brain tumor not associated with increased mortality, but safe routine discharge

OBJECTIVE

Interhospital transfer (IHT) to obtain a higher level of care for pediatric patients requiring neurosurgical interventions is common. Pediatric patients with malignant brain tumors often require subspecialty care commonly provided at specialized centers. The authors aimed to assess the impact of IHT in pediatric neurosurgical patients with malignant brain tumors to identify areas of improvement in treatment of this patient population.

METHODS

Pediatric patients (age < 19 years) with malignant primary brain tumors undergoing craniotomy for resection between 2010 and 2018 were retrospectively identified in the Nationwide Readmissions Database. Patient and hospital data for each index admission provided by the Nationwide Readmissions Database was analyzed by univariate and multivariate analyses. Further analysis evaluated association of IHT on specific patient- or hospital-related characteristics.

RESULTS

In a total of 2279 nonelective admissions for malignant brain tumors in pediatric patients, the authors found only 132 patients (5.8%) who underwent IHT for a higher level of care. There is an increased likelihood of transfer when a patient is younger (< 7 years old, p = 0.006) or the disease process is more severe, as characterized by higher pediatric complex chronic conditions (p = 0.0004) and increased all patient refined diagnosis-related group mortality index (p = 0.02). Patients who are transferred (OR 1.87, 95% CI 1.04-3.35; p = 0.04) and patients who are treated at pediatric centers (OR 6.89, 95% CI 4.23-11.22; p < 0.0001) are more likely to have a routine discharge home. On multivariate analysis, transfer status was not associated with a longer length of stay (incident rate ratio 1.04, 95% CI 0.94-1.16; p = 0.5) or greater overall costs per patient ($20,947.58, 95% CI -$35,078.80 to $76,974.00; p = 0.50). Additionally, IHT is not associated with increased likelihood of death or major complication.

CONCLUSIONS

IHT has a significant role in the outcome of pediatric patients with malignant brain tumors. Transfer of this patient population to hospitals providing subspecialized care results in a higher level of care without a significant burden on overall costs, risks, or mortality.

A Simple Grading Scale for Predicting Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy

INTRODUCTION

Hemorrhagic transformation, especially symptomatic intracranial hemorrhage (sICH), is a common complication after mechanical embolectomy. This study explored a grading scale based on clinical and radiological parameters to predict sICH after mechanical embolectomy.

METHODS

Demographic and clinical data were retrospectively collected from patients with acute ischemic stroke treated with mechanical embolectomy at West China Hospital. Clinical and radiological factors associated with sICH were identified and used to develop the "STBA" grading scale. This score was then validated using data from an independent sample at the First Affiliated Hospital of Kunming Medical University.

RESULTS

We analyzed 268 patients with acute ischemic stroke who were treated with mechanical embolectomy at West China Hospital, of whom 30 (11.2%) had sICH. Patients were rated on an "STBA" score ranging from 0 to 6 based on whether systolic blood pressure was ≥145 mm Hg at admission (yes = 2 points; no = 0 points), time from acute ischemic stroke until groin puncture was ≥300 min (yes = 1; no = 0), blood glucose was ≥8.8 mmol/L (yes = 1; no = 0), and the Alberta Stroke Program Early Computed Tomography score at admission was 0-5 (2 points), 6-7 (1 point), or 8-10 (0 points). The STBA score showed good discrimination in the derivation sample (area under the receiver operating characteristic curve = 0.858) and in the validation sample (area = 0.814).

CONCLUSIONS

The STBA score may be a reliable clinical scoring system to predict sICH in acute ischemic stroke patients treated with mechanical embolectomy.

Stroke-related length of hospitalization trends and in-hospital mortality in Peru

Background

Peru faces challenges to provide adequate care to stroke patients. Length of hospitalization and in-hospital mortality are two well-known indicators of stroke care. We aimed to describe the length of stay (LOS) of stroke in Peru, and to assess in-hospital mortality risk due to stroke, and subtypes.

Methods

This retrospective cohort study used hospitalization registries coding with ICD-10 from 2002 to 2017 (N = 98,605) provided by the Ministry of Health; in-hospital mortality was available for 2016-2017 (N = 6,566). Stroke cases aged ≥35 years were divided into subarachnoid hemorrhage (I60), intracerebral hemorrhage (I61), cerebral infarction (I63), and stroke not specified as hemorrhage or infarction (I64). Data included stroke LOS and in-hospital mortality; socio-demographic and clinical variables. We fitted a region- and hospital level-stratified Weibull proportional hazard model to assess the in-hospital mortality.

Results

The median LOS was 7 days (IQR: 4-13). Hemorrhagic strokes had median LOS longer than ischemic strokes and stroke not specified as hemorrhage or infarction (P = <0.001). The case fatality rate (CFR) of patients with stroke was 11.5% (95% CI [10-12%]). Subarachnoid hemorrhage (HR = 2.45; 95% CI [1.91-3.14]), intracerebral hemorrhage (HR = 1.95; 95% CI [1.55-2.46]), and stroke not specified as hemorrhage or infarction (HR = 1.45; 95% CI [1.16-1.81]) were associated with higher in-hospital mortality risk in comparison to ischemic strokes.

Discussion

Between 2002 and 2017, LOS due to stroke has not changed in Peru in stroke patients discharged alive. Hemorrhagic cases had the longest LOS and highest in-hospital mortality risk during 2016 and 2017. The findings of our study seem to be consistent with a previous study carried out in Peru and similar to that of HIC and LMIC, also there is an increased median LOS in stroke cases managed in specialized centers. Likewise, LOS seems to depend on the type of stroke, where ischemic stroke cases have the lowest LOS. Peru needs to improve access to stroke care.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care

Background

Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed.

Methods

A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients.

The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke.

Discussion

Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02653-x.

High Risk Features Contributing to 30-Day Readmission After Acute Ischemic Stroke: A Single Center Retrospective Case-Control Study

BACKGROUND AND PURPOSE

Risk of 30-day stroke readmission has been attributed to medical comorbidities, stroke severity, and hospitalization metrics. The leading etiologies appear to vary across institutions and remain a moving target. We hypothesized that patients with increased medical complexity have higher odds of 30-day readmission and the immediate time after discharge may be most vulnerable. We aimed to characterize patients with 30-day readmission after acute ischemic stroke (IS) and identify predictors of post-IS readmission.

METHODS

We performed a retrospective case-control study analyzing post-IS 30-day readmission between January 2016-December 2019 using data from Mount Sinai Hospital's Get With The Guidelines database. We performed chi square analyses and multivariate adjusted logistic regression model including age, sex, coronary artery disease (CAD), renal insufficiency (RI), history of prior stroke or TIA, length of stay (LOS) > 7, and NIHSS ≥ 5.

RESULTS

6.7% (n = 115) of 1,706 IS encounters had 30-day readmission. The 115 cases were compared to 1,591 controls without 30-day readmission. In our adjusted model, CAD (OR = 1.7, p = 0.01), history of prior stroke or TIA (OR = 1.6, p = 0.01), LOS >7 (OR = 1.7, p = 0.02), and NIHSS ≥ 5 (OR = 4.5, p < 0.001) predicted 30-day readmission. 65% (n = 75) of readmitted patients had readmission within 14 days post-discharge.

CONCLUSIONS

Patients with post-IS 30-day readmission were more likely to have complex medical comorbidities and history of stroke or TIA compared to controls. Patients with more severe stroke and longer LOS may benefit from individualized transition of care plans and closer follow up during the vulnerable 30-day post-stroke period.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Endovascular Thrombectomy Versus Bridging Thrombolysis: Real-World Efficacy and Safety Analysis Based on a Nationwide Registry Study

Background

It was uncertain if direct endovascular thrombectomy (ET) was superior to bridging thrombolysis (BT) for patients with acute ischemic stroke caused by large‐vessel occlusions. We aimed to examine real‐world clinical outcomes of ET using nationwide registry data in China and to compare the efficacy and safety between BT and direct ET.

Methods and Results

Patients treated with ET from a nationwide registry study in China were included. Rapid neurological improvement, intracranial hemorrhage, and in‐hospital mortality were compared between the 2 groups using multivariate logistic models and propensity‐score matching analyses. A total of 7674 patients from 592 stroke centers were included. The median onset‐to‐puncture time, onset‐to‐door time, and door to puncture time were 290, 170, and 99 minutes, respectively. A total of 2069 (27.0%) patients received BT treatment. Patients in the BT group had a significantly shorter onset‐to‐puncture time (235 versus 323 minutes; P<0.001) and onset‐to‐door time (90 versus 222 minutes; P<0.001) compared with the direct ET group. The prior use of intravenous thrombolysis was associated with a higher rate of rapid neurological improvement (adjusted odds ratio [OR], 0.83; 95% CI, 0.71–0.96) and higher risk of intracranial hemorrhage (adjusted OR, 1.46; 95% CI, 1.18–1.80) in multivariate analyses and propensity‐score matching analyses.

Conclusions

This study reflects the current application of ET in China. More patients received direct ET than BT. Our results suggested that favorable short‐term outcomes could be achieved with BT compared with direct ET. Higher risk of intracranial hemorrhage was observed in the BT group.

Delayed Thrombectomy Center Arrival is Associated with Decreased Treatment Probability

BACKGROUND

Endovascular thrombectomy (EVT) is effective in reducing disability in selected patients with stroke and large vessel occlusion (LVO), but access to this treatment is suboptimal.

AIM

We examined the proportion of patients with LVO who did not receive EVT, the reasons for non-treatment, and the association between time from onset and probability of treatment.

METHODS

We conducted a retrospective cohort study of consecutive patients with acute stroke and LVO presenting between January 2017 and June 2018. We used multivariable log-binomial models to determine the association between time and probability of treatment with and without adjustment for age, sex, dementia, active cancer, baseline disability, stroke severity, and evidence of ischemia on computerized tomography.

RESULTS

We identified 256 patients (51% female, median age 74 [interquartile range, IQR 63.5, 82.5]), of whom 59% did not receive EVT. The main reasons for not treating with EVT were related to occlusion characteristics or infarct size. The median time from onset to EVT center arrival was longer among non-treated patients (218 minutes [142, 302]) than those who were treated (180 minutes [104, 265], p = 0.03). Among patients presenting within 6 hours of onset, the relative risk (RR) of receiving EVT decreased by 3% with every 10-minute delay in arrival to EVT center (adjusted RR 0.97 CI95 [0.95, 0.99]). This association was not found in the overall cohort.

CONCLUSIONS

The proportion of patients with acute stroke and confirmed LVO who do not undergo EVT is substantial. Minimizing delays in arrival to EVT center may optimize the delivery of this treatment.