Direct transfer for thrombectomy in patients with large vessel occlusions on computed tomography angiography results in safe revascularization

Abstract

INTRODUCTION: Endovascular mechanical thrombectomy (EVT) has become the standard of care treatment for both intravenous tissue plasminogen activator eligible and ineligible patients presenting with an acute ischemic stroke due to a large vessel occlusion (LVO) within 24 h. Due to limited access to EVT, patients typically present to a non-EVT-capable center and are transferred to a larger, EVT-capable center. Quality improvement work has focused on improving this process to shorten the time to definitive recanalization of the affected vessel. MATERIALS AND METHODS: We retrospectively reviewed 98 consecutive patients who were transferred from an outside institution to our Comprehensive Stroke Center from July 2019 to September 2021. Thirty-nine of these patients had a diagnosed LVO at the transferring center on computed tomography angiography and were transferred directly to the angiography suite (DAT) whereas 59 patients were transferred to our Emergency Department for further imaging (EDT). Three of the patients in the DAT group did not undergo thrombectomy as there was no LVO identified on catheter angiography and were excluded from the study. RESULTS: Demographic and medical comorbidities were similar between the two groups. The DAT group had more severe strokes on presentation compared to the EDT group as measured by the National Institute of Health Stroke Severity (17.5 vs. 15, P = 0.048). Last known well (LKW) to arrival time in the angiography suite was significantly shorter in the DAT group (280 min vs. 474 min, P = 0.002). Patients in the DAT group were revascularized faster than the EDT group relative to LKW (320 min vs. 534 min, P < 0.001) while door-to-groin puncture and door-to-revascularization rates were similar. Modified Rankin score, incidence of symptomatic intracranial hemorrhage, and need for decompressive hemicraniectomy were similar between the two groups. Successful revascularization as measured by thrombolysis in cerebral infarction score occurred at a higher rate in the DAT group but was not statistical significance (97% vs. 85%, P = 0.055). DISCUSSION/CONCLUSION: DAT resulted in safe EVT compared to EDT with significant improvement in LKW to angiography suite presentation and subsequent vessel recanalization. Patients who underwent DAT experienced similar functional outcomes compared to EDT despite experiencing more severe strokes.

Keywords

• acute stroke
• computed tomography angiography
• large vessel occlusion
• mechanical thrombectmy