Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

STRATIS Investigators

Research output: Contribution to journalArticle

53 Citations (Scopus)

Abstract

BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.

METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.

RESULTS: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.

CONCLUSIONS: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.

CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.

Original languageEnglish (US)
Pages (from-to)2311-2321
Number of pages11
JournalCirculation
Volume136
Issue number24
DOIs
StatePublished - Dec 12 2017
Externally publishedYes

Fingerprint

Thrombectomy
Registries
Stroke
Equipment and Supplies
Tissue Plasminogen Activator
Patient Transfer
Odds Ratio
Confidence Intervals
Therapeutics
Clinical Trials
Mortality

Keywords

  • emergency medical services
  • endovascular treatment
  • ischemic stroke
  • stent retriever
  • systems of care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

@article{211eb2e828c5482cacc55f46e430ae15,
title = "Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)",
abstract = "BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.RESULTS: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0{\%} (299/498) achieving functional independence compared with 52.2{\%} (213/408) in the transfer group (odds ratio, 1.38; 95{\%} confidence interval, 1.06-1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4{\%} (236/498) of direct patients versus 38.0{\%} (155/408) of transfer patients (odds ratio, 1.47; 95{\%} confidence interval, 1.13-1.92; P=0.005). Mortality did not differ between the 2 groups (15.1{\%} for direct, 13.7{\%} for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.CONCLUSIONS: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.",
keywords = "emergency medical services, endovascular treatment, ischemic stroke, stent retriever, systems of care",
author = "{STRATIS Investigators} and Froehler, {Michael T.} and Saver, {Jeffrey L.} and Zaidat, {Osama O.} and Reza Jahan and Aziz-Sultan, {Mohammad Ali} and Klucznik, {Richard P.} and Haussen, {Diogo C.} and Hellinger, {Frank R.} and Yavagal, {Dileep R.} and Yao, {Tom L.} and Liebeskind, {David S.} and Jadhav, {Ashutosh P.} and Rishi Gupta and Hassan, {Ameer E.} and Martin, {Coleman O.} and Hormozd Bozorgchami and Ritesh Kaushal and Nogueira, {Raul G.} and Gandhi, {Ravi H.} and Peterson, {Eric C.} and Dashti, {Shervin R.} and Given, {Curtis A.} and Mehta, {Brijesh P.} and Vivek Deshmukh and Sidney Starkman and Italo Linfante and McPherson, {Scott H.} and Peter Kvamme and Grobelny, {Thomas J.} and Hussain, {Muhammad S.} and Ike Thacker and Nirav Vora and Chen, {Peng Roc} and Monteith, {Stephen J.} and Ecker, {Robert D.} and Schirmer, {Clemens M.} and Eric Sauvageau and Alex Abou-Chebl and Derdeyn, {Colin P.} and Lucian Maidan and Aamir Badruddin and Siddiqui, {Adnan H.} and Dumont, {Travis M.} and Abdulnasser Alhajeri and Taqi, {M. Asif} and Khaled Asi and Jeffrey Carpenter and Alan Boulos and Gaurav Jindal and Puri, {Ajit S.}",
year = "2017",
month = "12",
day = "12",
doi = "10.1161/CIRCULATIONAHA.117.028920",
language = "English (US)",
volume = "136",
pages = "2311--2321",
journal = "Circulation",
issn = "0009-7322",
publisher = "Lippincott Williams and Wilkins",
number = "24",

}

TY - JOUR

T1 - Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

AU - STRATIS Investigators

AU - Froehler, Michael T.

AU - Saver, Jeffrey L.

AU - Zaidat, Osama O.

AU - Jahan, Reza

AU - Aziz-Sultan, Mohammad Ali

AU - Klucznik, Richard P.

AU - Haussen, Diogo C.

AU - Hellinger, Frank R.

AU - Yavagal, Dileep R.

AU - Yao, Tom L.

AU - Liebeskind, David S.

AU - Jadhav, Ashutosh P.

AU - Gupta, Rishi

AU - Hassan, Ameer E.

AU - Martin, Coleman O.

AU - Bozorgchami, Hormozd

AU - Kaushal, Ritesh

AU - Nogueira, Raul G.

AU - Gandhi, Ravi H.

AU - Peterson, Eric C.

AU - Dashti, Shervin R.

AU - Given, Curtis A.

AU - Mehta, Brijesh P.

AU - Deshmukh, Vivek

AU - Starkman, Sidney

AU - Linfante, Italo

AU - McPherson, Scott H.

AU - Kvamme, Peter

AU - Grobelny, Thomas J.

AU - Hussain, Muhammad S.

AU - Thacker, Ike

AU - Vora, Nirav

AU - Chen, Peng Roc

AU - Monteith, Stephen J.

AU - Ecker, Robert D.

AU - Schirmer, Clemens M.

AU - Sauvageau, Eric

AU - Abou-Chebl, Alex

AU - Derdeyn, Colin P.

AU - Maidan, Lucian

AU - Badruddin, Aamir

AU - Siddiqui, Adnan H.

AU - Dumont, Travis M.

AU - Alhajeri, Abdulnasser

AU - Taqi, M. Asif

AU - Asi, Khaled

AU - Carpenter, Jeffrey

AU - Boulos, Alan

AU - Jindal, Gaurav

AU - Puri, Ajit S.

PY - 2017/12/12

Y1 - 2017/12/12

N2 - BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.RESULTS: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.CONCLUSIONS: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.

AB - BACKGROUND: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.METHODS: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.RESULTS: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.CONCLUSIONS: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.

KW - emergency medical services

KW - endovascular treatment

KW - ischemic stroke

KW - stent retriever

KW - systems of care

UR - http://www.scopus.com/inward/record.url?scp=85039071190&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85039071190&partnerID=8YFLogxK

U2 - 10.1161/CIRCULATIONAHA.117.028920

DO - 10.1161/CIRCULATIONAHA.117.028920

M3 - Article

VL - 136

SP - 2311

EP - 2321

JO - Circulation

JF - Circulation

SN - 0009-7322

IS - 24

ER -