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).

Autor:	Froehler MT; Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.). m.froehler@vanderbilt.edu., Saver JL; University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)., Zaidat OO; St Vincent Mercy Hospital, Toledo, OH (O.O.Z.)., Jahan R; University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)., Aziz-Sultan MA; Brigham and Women's Hospital, Boston, MA (M.A.A.-S.)., Klucznik RP; Methodist Hospital, Houston, TX (R.P.K.)., Haussen DC; Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)., Hellinger FR Jr; Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.)., Yavagal DR; University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)., Yao TL; Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.)., Liebeskind DS; University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)., Jadhav AP; University of Pittsburgh Medical Center, PA (A.P.J.)., Gupta R; WellStar Neurosciences Network, WellStar Kennestone Regional Medical Center, Marietta, GA (R.G.)., Hassan AE; Valley Baptist Medical Center, Harlingen, TX (A.E.H.)., Martin CO; St. Luke's Hospital of Kansas City, MO (C.O.M.)., Bozorgchami H; Oregon Health and Science University Hospital, Portland (H.B.)., Kaushal R; Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., N.H.M.-K.)., Nogueira RG; Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)., Gandhi RH; Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.)., Peterson EC; University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)., Dashti SR; Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.)., Given CA 2nd; Baptist Health Lexington/Central Baptist, KY (C.A.G.)., Mehta BP; South Broward Hospital, Hollywood, FL (B.P.M.)., Deshmukh V; Providence St Vincent Medical Center, Portland, OR (V.D.)., Starkman S; University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)., Linfante I; Baptist Hospital of Miami, FL (I.L.)., McPherson SH; St Dominic's-Jackson Memorial Hospital, MS (S.H.M.)., Kvamme P; University of Tennessee Medical Center, Knoxville (P.K.)., Grobelny TJ; Advocate Christ Medical Center, Oak Lawn, IL (T.J.G.)., Hussain MS; Cleveland Clinic, OH (M.S.H.)., Thacker I; Baylor University Medical Center, Dallas, TX (I.T.)., Vora N; OhioHealth Riverside Methodist Hospital, Columbus (N.V.)., Chen PR; Memorial Hermann Texas Medical Center, Houston (P.R.C.)., Monteith SJ; Swedish Medical Center First Hill Campus, Seattle, WA (S.J.M.)., Ecker RD; Maine Medical Center, Portland (R.D.E.)., Schirmer CM; Geisinger Clinic, Danville, PA (C.M.S.)., Sauvageau E; Baptist Medical Center-Jacksonville, FL (E.S.)., Abou-Chebl A; Baptist Hospital Louisville, KY (A.A.-C.)., Derdeyn CP; Barnes Jewish Hospital, St Louis, MO (C.P.D.)., Maidan L; Mercy San Juan Medical Center and Mercy General, Carmichael, CA (L.M.)., Badruddin A; Presence St Joseph Medical Center, Joliet, IL (A.B.)., Siddiqui AH; Buffalo General Medical Center, NY (A.H.S.)., Dumont TM; University of Arizona Medical Center, Tucson (T.M.D.)., Alhajeri A; University of Kentucky Hospital, Lexington (A.A.)., Taqi MA; Los Robles Medical Center, Thousand Oaks, CA (M.A.T.)., Asi K; Aurora Hospital, Milwaukee, WI (K.A.)., Carpenter J; West Virginia University/Ruby Memorial Hospital, Morgantown (J.C.)., Boulos A; Albany Medical Center, NY (A.B.)., Jindal G; University of Maryland Medical Center, Baltimore (G.J.)., Puri AS; University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)., Chitale R; Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.)., Deshaies EM; Crouse Hospital, Syracuse, NY (E.M.D.)., Robinson DH; Virginia Mason Medical Center, Seattle, WA (D.H.R.)., Kallmes DF; Mayo Clinic-Rochester, MN (D.F.K.)., Baxter BW; Erlanger Medical Center, Chattanooga, TN (B.W.B.)., Jumaa MA; ProMedica Toledo Hospital, OH (M.A.J.)., Sunenshine P; Banner University Medical Center, Phoenix, AZ (P.S.)., Majjhoo A; McLaren Flint, MI (A.M.)., English JD; California Pacific Medical Center, San Francisco, CA (J.D.E.)., Suzuki S; University of California, Irvine, Orange (S.S.)., Fessler RD; St John Providence Hosptial, Detroit, MI (R.D.F.)., Delgado Almandoz JE; Abbott Northwestern Hospital, Minneapolis, MN (J.E.D.A.). Carolinas Medical Center, Charlotte, NC., Martin JC, Mueller-Kronast NH; Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., N.H.M.-K.).
Jazyk:	angličtina
Zdroj:	Circulation [Circulation] 2017 Dec 12; Vol. 136 (24), pp. 2311-2321. Date of Electronic Publication: 2017 Sep 24.
DOI:	10.1161/CIRCULATIONAHA.117.028920
Abstrakt:	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. (© 2017 The Authors.)
Databáze:	MEDLINE
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