Stroke

Key Points:

• Registry study calculates proportion of patients with acute ischemic stroke eligible for endovascular therapy
• Patients treated at comprehensive stroke center were eligible at similar levels vs those who seen in prior RCTs

With solid development and planning of a comprehensive stroke network, the majority of patients with acute ischemic stroke who arrive early enough and are eligible for endovascular therapy can receive this care, according to research published online June 17, 2016, ahead of print in Stroke.

Approximately one-quarter to one-third of patients treated with IV thrombolysis qualify as candidates for endovascular therapy, depending on the stringency of criteria used, report Peter Vanacker, MD, PhD, of the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland), and colleagues.

With Acute Stroke Registry and Analysis of Lausanne (ASTRAL) registry data, the resarchers examined characteristics of 2,704 patients with acute ischemic stroke who presented at their comprehensive stroke center between 2003 and 2014. Of these patients, 26.8% were transferred from another hospital.

The investigators used two methods to categorize whether patients were eligible for acute revacularization (either IV thrombolysis or endovascular therapy)—Association/American Stroke Association (AHA/ASA) guideline class I-IIa criteria and less restrictive criteria adapted from randomized controlled trials and clinical practice. Maximum onset-to-door time window for IV thrombolysis eligibility was 3.5 hours (allowing for a door-to-needle delay of ≤ 60 minutes) and for endovascular therapy eligibility was 4.5 hours (with door-to-groin delay ≤ 90 minutes).

Overall, 2.9% of patients were candidates for endovascular therapy based on AHA/ASA guidelines and 4.9% based on trial/clinical data. Using the more liberal time frame of 6 hours since symptom onset, 10.5% were eligible for an endovascular approach based on AHA/ASA criteria and 17.7% based on trial/clinical data.

Logistric regression analysis revealed multiple predictors of AHA/ASA-based eligibility for endovascular therapy (table 1).

Table 1. Predictors of AHA/ASA-Based Eligibility for Endovascular Therapy

With regard to IV thrombolysis, 24.6% of patients arriving within 24 hours after symptom onset were eligible for this therapy. If they arrived within 6 hours, 44.8% were eligible.

Theoretical Proportions Achievable

“Constant development of a stroke network and improved intrahospital performance made it possible to achieve these proportions in real life,” they note. “Our data may allow planning for appropriate resource needs in different settings and identification of [endovascular therapy]-eligible patients in the prehospital setting based on clinical variables.”

In reality, the level of success was slightly lower than predicted eligibility: 20.4% of all patients with acute ischemic stroke arriving within 24 hours of symptom onset received IV thrombolysis within 4.5 hours and 11.0% by endovascular therapy within 6 hours in 2013-2014, the researchers acknowledge, adding, “When considering only the local population based primarily on our stroke center, these proportions were 11.1% for [IV thrombolysis] and 5.8% for [endovascular therapy].”

They note several reasons as to why the treated numbers of patients at their center fell below the eligible number. These include “deficiencies in the intrahospital chain of management” (such as nonrecognition of stroke, CT overload, delays from poor organization or mindset, miscommunication, or personal decision by the on-call neurologist and the fact that knowledge of endovascular therapy’s effectiveness was limited at the time.

Source:

Vanacker P, Lambrou D, Eskandari A, et al. Eligibility and predictors for acute revascularization procedures in a stroke center. Stroke. 2016;Epub ahead of print.

Disclosures:

• Dr. Vanacker reports no relevant conflicts of interest.

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