Stroke

It’s not yet known whether the practice improves outcomes or how best to triage patients on a case-by-case basis.

Transfer patients who are identified at their referring facilities as having acute ischemic stroke due to large-vessel occlusion (LVO) can be safely and feasibly admitted directly to the angiography suite, according to a single-center study. 

Yet while bypassing the emergency department (ED) did result in more rapid recanalization time in the study, there was no difference in final outcomes.

The investigators, led by Ashutosh P. Jadhav, MD, PhD (University of Pittsburgh Medical Center, Pittsburgh, PA), conducted a retrospective review of their prospectively maintained database, identifying all consecutive patients transferred to their facility for consideration of endovascular therapy for LVO between January 2013 and October 2016. Among the 261 patients who underwent mechanical thrombectomy, 111 were admitted directly to the neuroangiography suite and 150 were transferred to the ED before undergoing intra-arterial therapy. An additional 108 patients with LVO were transferred to the ED but did not receive intra-arterial therapy. The findings were published online May 23, 2017, ahead of print in Stroke.

Baseline characteristics were similar for the 3 groups of patients, except that median ASPECTS score was lower among those who did not undergo intra-arterial therapy compared with those who did. Functional independence at 90 days was achieved more frequently among intra-arterial therapy patients, a finding that was independent of whether patients were admitted to the ED or went directly to the angiography suite.

Baseline Characteristics and Outcome

*Statistically significant vs. both other groups

Complete-recanalization rates and puncture-to-recanalization times were similar for those who underwent intra-arterial therapy, regardless of whether they were admitted to the ED or directly to the angiography suite. However, direct admission to the angiography suite was associated with more rapid times from hospital arrival to groin access and from door to recanalization.

Revascularization and Timing by Location of Admission

Must be Decided Case-by-Case

In an email to NVX, Enrique Leira, MD (University of Iowa College of Medicine, Iowa City), said that, while there are not yet any comprehensive data on whether bypassing the ED is feasible across a variety centers, “anecdotal experiences suggests that this might be done on a case-to-case basis.”

There are limits, however. “Depending on the amount time that has elapsed since the last CT scan at the local hospitals, repeating the neuroimaging might be advisable before proceeding with mechanical thrombectomy,” he explained. “In those cases, the ED might be a more rapid setting for obtaining imaging than the OR.”

But the authors note in their paper that “the benefit of transfer to the ED for the purposes of obtaining additional imaging may be called into question because the additional imaging leads to further time delays with low likelihood of identifying patients harmed by the intervention.”

Leira also pointed out that patients with LVO who have developed additional systemic issues, such as cardiovascular or respiratory comorbidities, might be better served with admission to the ED rather than the angiography suite. Indeed, the authors note that patients who become hemodynamically unstable or who require intubation during transfer will likely require stabilization and evaluation in the ED.

Jadhav et al also mention that false-positive activation of the angiography suite is another potential disadvantage of admitting directly there. False positives occurred only 7 times in their study, but they acknowledge it would likely have been higher if most patients had not undergone CT angiography prior to transfer. Ultimately, they conclude, “some degree of overtriaging is inevitable to minimize reperfusion delays in such highly time-sensitive conditions.”

According to Leira, the next step for research in this area should be to “develop a stratification scheme of which patients are more likely to benefit from direct OR transfer, and to prove in a clinical trial that this strategy results in better outcomes.” The authors also note that prospective trials are needed to see if direct transfer can improve outcomes.

Source:

Jadhav AP, Kenmuir CL, Aghaebrahim A, et al. Interfacility transfer directly to the neuroangiography suite in acute ischemic stroke patients undergoing thrombectomy. Stroke. 2017;Epub ahead of print.

Disclosures:

Leira and Jadhav report no relevant conflicts of interest.

Related Stories:

• Neurosurgical Emergency Transfers: There’s Room for Improvement
• National Database Study Confirms Uptick in Mortality With Transfer for Thrombectomy
• Interhospital Transfers Produce Important Delays in Stroke Revascularization

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