The Source for Neurovascular News and Education

March 29, 2024

If the experience of one tertiary center is any guide, many risk factors for death and neurological deterioration are modifiable.

 

While a great deal more information is needed to know how best to manage patients transferred for neurosurgery, the experience of one tertiary center suggests that several risk factors for poor outcome—including the presence of hydrocephalus and the use of anticoagulant and antiplatelet drugs—can be modified.

The findings were published online March 20, 2017 ahead of print in Neurosurgery.

“Interhospital patient transfer is a common, and often the only way of providing the necessary high quality care to patients with acute intracranial pathology who initially arrive to facilities with no or limited neurosurgical coverage,” Maxim Mokin, MD, PhD (University of South Florida, Tampa, FL), who wasn’t involved in the study, told Neurovascular Exchange in an email. “Thus, it is important to understand its limitations so we can improve the quality of care provided.”

Ali Alaraj, MD, (University of Illinois at Chicago, Chicago, IL) and colleagues reviewed all 1,429 consecutive patient transfers involving cranial pathology to a tertiary academic neurosurgery service over a 2-year period from January 2012 to December 2013. They evaluated multiple risk factors, including demographics, medical comorbidities, hydrocephalus, anticoagulant use, transfer diagnosis, Glasgow Coma Scale score, and transfer time.

Overall, there were 154 instances of neurological decline in transit (10.8%) and 99 deaths (6.9%). Multivariate analysis revealed that independent predictors of neurological decline were the presence of hydrocephalus or intracerebral hemorrhage and the use of clopidogrel, warfarin, or other systemic anticoagulants.


Independent Predictors of Neurological Decline

 

OR (95% CI)

P Value

Hydrocephalus

1.95 (1.22-3.09)

0.05

Clopidogrel Use

4.33 (1.63-11.50)

0.03

Warfarin Use

2.62 (1.35-5.06)

0.04

Use of Other Systemic Anticoagulant

10.10 (3.63-28.11)

< 0.01

Intracerebral (Parenchymal) Hemorrhage

3.37 (2.36-4.81)

< 0.01


Independent predictors of death were older age, neurological deterioration, the presence of hyperlipidemia, renal failure, hydrocephalus, or intracerebral failure, and use of clopidogrel or warfarin.


Independent Predictors of Death

 

OR (95% CI)

P Value

Age

1.02 (1.01-1.033)

0.004

Deterioriation

2.07 (1.21-3.56)

0.008

Hyperlipidemia

0.39 (0.19-0.81)

0.01

Renal Failure

2.25 (1.02-4.97)

0.05

Hydrocephalus

2.13 (1.25-3.64)

0.006

Clopidogrel Use

4.59 (1.70-12.39)

0.003

Warfarin Use

2.26 (1.07-4.78)

0.03

Intracerebral (Parenchymal) Hemorrhage

2.01 (1.28-3.18)

0.003

 

An analysis based on transfer diagnosis showed that patients with intracerebral hemorrhage had the highest incidence of mortality, at 12.7% (P = 0.003). There was also a nonsignificant trend toward patients who ultimately died being transferred faster than survivors.

The study was published along with three comments from experts in the field.

In their comment, Justin Mascitelli, MD, and J. Mocco, MD (New York, NY), point out that most of the risk factors for neurological decline were modifiable or preventable. “Hydrocephalus is a complication that is rapidly treatable by a neurosurgeon with a ventriculostomy,” they write. “This raises the question of neurosurgical coverage at the sending hospital, which the authors state was infrequent, as well as the ability to direct patients with hydrocephalus to hospitals with neurosurgical coverage. The use of mobile CT scanners has already been employed in stroke and this provides more indirect evidence for its use. Additionally, all sending emergency rooms should be equipped with the resources to rapidly reverse antiplatelet and anticoagulant medications prior to transfer.”


More Information Needed

Comments by Debraj Mukherjee, MD (Los Angeles, CA), as well as Sanjay Konakondla, MD (Danville, PA), and Clemens M. Schirmer, MD (Wilkes Barre, PA), call for additional information on the use of and availability of antiplatelet and anticoagulant reversal agents prior to or during transfer.

Konakondla and Schirmer add that modality of transfer (ground versus air) should be included in preliminary transfer recommendations, noting that “the inherent nature of the disease also cannot be ignored. A comparison of similar pathologies between patients who were transferred from other hospitals versus patients who had initial evaluation at this same tertiary center may yield interesting results.”

To NVX, Mokin said that the study has other limitations, including a single center design and lack of information on how acute the transfers were. “For example, it is well documented that acute stroke transfers, when compared to direct admissions to a comprehensive stroke center, will result in worse outcomes in patients requiring acute revascularization endovascular therapy,” he observed. “Less is known on how transfer process affects outcomes in patients with intracranial bleeds. Often, it is the timing of the transfer (immediately or several days after the admission) that will affect the outcome.”

It’s necessary, Mokin said, “to develop a better understanding of how such transfers occur, which would require communication among hospitals and health care providers. This is challenging given the complexities of current healthcare system and the evolving trend in hospitals joining larger networks and increased competition.”

 


Source:

Alaraj A, Esfahani DR, Hussein AE, et al. Neurosurgical emergency transfers: an analysis of deterioration and mortality. Neurosurgery. 2017;Epub ahead of print.

 

Disclosures:

  • Alaraj reports being a consultant for Cordis-Codman.
  • Mokin reports no relevant conflicts of interest.

 

Related Stories:

 

Monday, October 26 2020

Stroke rates for the balloon-expandable device far exceeded those of the Evolut R; conscious...

Read More »

Monday, October 26 2020

Safety goals were met in the trial, but better efficacy may require ensuring complete coverage of...

Read More »

Wednesday, September 23 2020

The findings “reinforce that this is absolutely the right thing to do and that we need to set up...

Read More »

Tuesday, July 21 2020

Whether COVID-19 adds risk by virtue of being a comorbidity or due to direct effects is unknown. A...

Read More »

Friday, May 8 2020

In some cases, large strokes are the first presentation of COVID-19 in younger patients, but...

Read More »

Monday, April 6 2020

Clopidogrel added to rivaroxaban and aspirin increased bleeding with no added protection from limb or...

Read More »

Monday, April 6 2020

Although rivaroxaban patients had more bleeding, the events were not severe and none were...

Read More »

Monday, April 6 2020

The strokes do not appear related to valve thrombosis or structural degeneration, but rather to...

Read More »

Thursday, January 23 2020

A fundamental unanswered question is whether any type of oral anticoagulation is needed in the...

Read More »

Monday, January 6 2020

Though periprocedural results look good, there are some questions about its rapid rise when...

Read More »

Wednesday, August 21 2019

In addition, an infarct in a new territory did not emerge as an independent predictor of...

Read More »

Wednesday, August 21 2019

The procedure—a hybrid of surgical and endovascular techniques—offers low stroke rates and a short...

Read More »