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Protocol for patients with stroke, large-vessel occlusion confers improved outcomes
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Positive outcome rates for patients with ischemic stroke and emergent large-vessel occlusion were doubled when a standardized protocol for primary stroke centers was fully executed, according to findings published in JAMA Neurology.
The study also showed that compared with partial execution, fully executed protocols resulted in a reduction in the time between arrival at a primary stroke center and groin puncture at a comprehensive stroke center.
“Time has a profound effect on outcomes for patients with [emergent large-vessel occlusion],” Ryan A. McTaggart, MD, from the departments of diagnostic imaging, neurology and neurosurgery at Warren Alpert School of Medicine, Brown University, and colleagues wrote. “It is of paramount importance to maximize the efficiency of the transfer process for patients with [emergent large-vessel occlusion], which revolves around hospital processes at [primary stroke centers].”
Protocol to follow
Researchers conducted a retrospective cohort study, consisting of 14 regional primary stroke centers unfamiliar with the management of patients with emergent large-vessel occlusion, which were instructed to notify the comprehensive stroke center on arrival, perform CT angiography at the same time as noncontract CT of the brain and within 30 minutes of arrival, and share imaging data with the comprehensive stroke center using a cloud-based platform when treating patients presenting with a Los Angeles Motor Scale score of 4 or higher.
Between July 1, 2015, and May 31, 2016, 101 patients were transferred from regional primary stroke centers to the comprehensive stroke center to receive mechanical thrombectomy for acute ischemic stroke. The comprehensive stroke center has established partnerships with 14 primary stroke centers located between 6.4 km and 73.6 km away.
Patients with internal carotid artery or middle cerebral artery occlusion who were transferred during a span of 7 months were stratified by whether the primary stroke center protocol was partially or fully executed.
Although 101 patients with confirmed emergent large-vessel occlusion were transported to the comprehensive stroke center during the study period, only 70 met the inclusion criteria.
The protocol was partially executed for 68.6% of participants (n = 48; mean age, 77 years) and executed in 31.4% of patients (n = 22; mean age, 76 years).
There was a reduction in the median time between primary stroke center arrival and comprehensive stroke center groin puncture, from 151 minutes (95% CI, 141-166) to 111 minutes (95% CI, 88-130) when the protocol was fully executed. This was primarily related to an improvement in the time spent at the primary stroke center, which was reduced from a median time of 104 minutes (95% CI, 82-112) to a median time of 64 minutes (95% CI, 51-71), according to the researchers.
Patients were twice as likely to have positive outcomes, defined as a 90-day modified Rankin scale score of 0 to 2, when the protocol was executed fully (50% vs. 25%; P<.04), McTaggart and colleagues wrote.
Collaboration needed
“McTaggart and colleagues challenge us to develop and interdisciplinary, team-based, protocolized approach to patients with potential [emergent large-vessel occlusion] presenting to nonendovascular centers,” Kori Sauser Zachrison, MD, MSc, from the department of emergency medicine, and Lee H. Schwamm, MD, from the department of neurology, both at Massachusetts General Hospital and Harvard Medical School, wrote in a related editorial. “As we do so, we must work together across disciplines to achieve an acceptable false-positive rate for the system, as well as rapid times from door in to door out and treatment time metrics to ensure best possible clinical outcomes for patients who undergo a thrombectomy.” – by Dave Quaile
Disclosure: The researchers, Schwamm and Zachrison report no relevant financial disclosures.
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