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)

被引：345

作者：

Froehler, Michael T. ^{[1
]}

Saver, Jeffrey L. ^{[2
]}

Zaidat, Osama O. ^{[3
]}

Jahan, Reza ^{[2
]}

Aziz-Sultan, Mohammad Ali ^{[4
]}

Klucznik, Richard P. ^{[5
]}

Haussen, Diogo C. ^{[6
]}

Hellinger, Frank R., Jr. ^{[7
]}

Yavagal, Dileep R. ^{[8
]}

Yao, Tom L. ^{[9
]}

Liebeskind, David S. ^{[2
]}

Jadhav, Ashutosh P. ^{[10
]}

Gupta, Rishi ^{[11
]}

Hassan, Ameer E. ^{[12
]}

Martin, Coleman O. ^{[13
]}

Bozorgchami, Hormozd ^{[14
]}

Kaushal, Ritesh ^{[15
]}

Nogueira, Raul G. ^{[6
]}

Gandhi, Ravi H. ^{[7
]}

Peterson, Eric C. ^{[8
]}

Dashti, Shervin R. ^{[9
]}

Given, Curtis A., II ^{[16
]}

Mehta, Brijesh P. ^{[17
]}

Deshmukh, Vivek ^{[18
]}

Starkman, Sidney ^{[2
]}

Linfante, Italo ^{[19
]}

McPherson, Scott H. ^{[20
]}

Kvamme, Peter ^{[21
]}

Grobelny, Thomas J. ^{[22
]}

Hussain, Muhammad S. ^{[23
]}

Thacker, Ike ^{[24
]}

Vora, Nirav ^{[25
]}

Chen, Peng Roc ^{[26
]}

Monteith, Stephen J. ^{[27
]}

Ecker, Robert D. ^{[28
]}

Schirmer, Clemens M. ^{[29
]}

Sauvageau, Eric ^{[30
]}

Abou-Chebl, Alex ^{[31
]}

Derdeyn, Colin P. ^{[32
]}

Maidan, Lucian ^{[33
]}

Badruddin, Aamir ^{[34
]}

Siddiqui, Adnan H. ^{[35
]}

Dumont, Travis M. ^{[36
]}

Alhajeri, Abdulnasser ^{[37
]}

Taqi, M. Asif ^{[38
]}

Asi, Khaled ^{[39
]}

Carpenter, Jeffrey ^{[40
]}

Boulos, Alan ^{[41
]}

Jindal, Gaurav ^{[42
]}

Puri, Ajit S. ^{[43
]}

机构：

[1] Vanderbilt Univ, Med Ctr, Nashville, TN 37235 USA

[2] Univ Calif Los Angeles, Los Angeles, CA USA

[3] St Vincent Mercy Hosp, Toledo, OH USA

[4] Brigham & Womens Hosp, 75 Francis St, Boston, MA 02115 USA

[5] Methodist Hosp, 6535 Fannin, Houston, TX 77030 USA

[6] Emory Univ, Sch Med, Grady Mem Hosp, Atlanta, GA USA

[7] Florida Hosp, Neurosci Inst, Winter Pk, FL USA

[8] Univ Miami, Miller Sch Med, Jackson Mem Hosp, Coral Gables, FL 33124 USA

[9] Norton Neurosci Inst, Norton Healthcare, Louisville, KY USA

[10] Univ Pittsburgh, Med Ctr, Pittsburgh, PA 15260 USA

[11] WellStar Kennestone Reg Med Ctr, WellStar Neurosci Network, Marietta, GA USA

[12] Valley Baptist Med Ctr, Harlingen, TX USA

[13] St Lukes Hosp Kansas City, Kansas City, MO USA

[14] Oregon Hlth & Sci Univ Hosp, Portland, OR USA

[15] Adv Neurosci Network Tenet South Florida, Delray Beach, FL USA

[16] Baptist Hlth Lexington Cent Baptist, Lexington, KY USA

[17] South Broward Hosp, Hollywood, FL USA

[18] Providence St Vincent Med Ctr, Portland, OR USA

[19] Baptist Hosp Miami, Miami, FL USA

[20] St Dominics Jackson Mem Hosp, Jackson, MS USA

[21] Univ Tennessee, Med Ctr, Knoxville, TN USA

[22] Advocate Christ Med Ctr, Oak Lawn, IL USA

[23] Cleveland Clin, Cleveland, OH 44106 USA

[24] Baylor Univ, Med Ctr, Dallas, TX USA

[25] OhioHlth Riverside Methodist Hosp, Columbus, OH USA

[26] Mem Hermann Texas Med, Houston, TX USA

[27] Swedish Med Ctr, First Hill Campus, Seattle, WA USA

[28] Maine Med Ctr, Portland, ME 04102 USA

[29] Geisinger Med Clin, Danville, PA USA

[30] Baptist Med Ctr, Jacksonville, FL USA

[31] Baptist Hosp, Louisville, KY USA

[32] Barnes Jewish Hosp, St Louis, MO 63110 USA

[33] Mercy San Juan Med Ctr & Mercy Gen, Carmichael, CA USA

[34] Presence St Joseph Med Ctr, Joliet, IL USA

[35] Buffalo Gen Med Ctr, Buffalo, NY USA

[36] Univ Arizona, Med Ctr, Tucson, AZ USA

[37] Univ Kentucky Hosp, Lexington, KY USA

[38] Los Robles Med Ctr, Thousand Oaks, CA USA

[39] Aurora Hosp, Milwaukee, WI USA

[40] West Virginia Univ, Ruby Mem Hosp, Morgantown, WV 26506 USA

[41] Albany Med Ctr, Albany, NY USA

[42] Univ Maryland, Med Ctr, Baltimore, MD 21201 USA

[43] Univ Massachusetts, Mem Med Ctr, Worcester, MA 01605 USA

[44] Crouse Hosp, Syracuse, NY USA

[45] Virginia Mason Med Ctr, Seattle, WA 98101 USA

[46] Mayo Clin, Rochester, MN USA

[47] Erlanger Med Ctr, Chattanooga, TN USA

[48] ProMed Toledo Hosp, Toledo, OH USA

[49] Banner Univ, Med Ctr, Phoenix, AZ USA

[50] McLaren Flint, Flint, MI USA

来源：

CIRCULATION | 2017年 / 136卷 / 24期

关键词：

emergency medical services; endovascular treatment; ischemic stroke; stent retriever; systems of care; RANDOMIZED CONTROLLED-TRIAL; INTRAVENOUS T-PA; ENDOVASCULAR THERAPY; GUIDELINES-STROKE; MECHANICAL THROMBECTOMY; CLINICAL-OUTCOMES; CARE; QUALITY; HEART; IMPROVEMENT;

D O I：

10.1161/CIRCULATIONAHA.117.028920

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

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.

引用

页码：2311 / 2321

页数：11

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