TY - JOUR
T1 - Interhospital transfer vs. direct presentation of patients with a large vessel occlusion not eligible for IV thrombolysis
AU - van Meenen, Laura C. C.
AU - Groot, Adrien E.
AU - Venema, Esmee
AU - Emmer, Bart J.
AU - Smeekes, Martin D.
AU - Kommer, Geert Jan
AU - Majoie, Charles B. L. M.
AU - Roos, Yvo B. W. E. M.
AU - Schonewille, Wouter J.
AU - Roozenbeek, Bob
AU - Coutinho, Jonathan M.
AU - van Zwam, Wim
AU - van Oostenbrugge, Robert Jan
AU - MR CLEAN Registry Investigators
N1 - Funding Information:
The MR CLEAN Registry was funded and carried out by Erasmus University Medical Center, Amsterdam UMC, and Maastricht University Medical Center. The study was additionally funded by the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie), which played no role in trial design and patient enrollment, nor in data collection, analysis, or writing of the article.
Funding Information:
Dr. Majoie reports grants from CVON/Dutch Heart Foundation, European Commission, TWIN Foundation and Stryker, outside the submitted work (paid to institution). In addition, Dr. Majoie is shareholder of Nico.lab, a company that focuses on the use of artificial intelligence for medical image analysis. Dr. Roos reports stockholdings from Nico.lab outside the submitted work. Dr. Coutinho reports grants from Medtronic outside the submitted work. Dr. Majoie, Dr. Roos, and Dr. Coutinho are (co-)investigators of the MR-CLEAN-NO IV trial (ISRCTN80619088). The other authors report no conflicts.
Publisher Copyright:
© 2020, The Author(s).
PY - 2020/7
Y1 - 2020/7
N2 - Background and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT. Methods We used data from the MR CLEAN Registry (2014-2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders. Results Of the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p <0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted beta = - 51.6, 95% CI: - 64.0 to - 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted beta = - 44.0, 95% CI: - 65.5 to - 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73-2.08). Conclusions In patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome.
AB - Background and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT. Methods We used data from the MR CLEAN Registry (2014-2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders. Results Of the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p <0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted beta = - 51.6, 95% CI: - 64.0 to - 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted beta = - 44.0, 95% CI: - 65.5 to - 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73-2.08). Conclusions In patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome.
KW - Patient transfer
KW - Thrombectomy
KW - Thrombolysis
KW - Stroke
KW - ACUTE ISCHEMIC-STROKE
KW - ENDOVASCULAR THROMBECTOMY
KW - REPERFUSION
KW - TIME
KW - CARE
KW - CIRCULATION
KW - ACCESS
U2 - 10.1007/s00415-020-09812-5
DO - 10.1007/s00415-020-09812-5
M3 - Article
C2 - 32266543
SN - 0340-5354
VL - 267
SP - 2142
EP - 2150
JO - Journal of Neurology
JF - Journal of Neurology
IS - 7
ER -