Abstract
Background and purpose
Randomized controlled trials have demonstrated that mechanical thrombectomy (MT) could provide more benefit than standard medical care for acute ischemic stroke (AIS) patients due to emergent large vessel occlusion. However, most primary stroke centers (PSCs) are unable to perform MT, and MT can only be performed in comprehensive stroke centers (CSCs) with on-site interventional neuroradiologic services. Therefore, there is an ongoing debate regarding whether patients with suspected AIS should be directly admitted to CSCs or secondarily transferred to CSCs from PSCs. This meta-analysis was aimed to investigate the two transportation paradigms of direct admission and secondary transfer, which one could provide more benefit for AIS patients treated with MT.
Methods
We conducted a systematic review and meta-analysis through searching PubMed, Embase and the Cochrane Library database up to March 2020. Primary outcomes are as follows: symptomatic intracerebral hemorrhage (sICH) within 7 days; favorable functional outcome at 3 months; mortality in hospital; mortality at 3 months; and successful recanalization rate.
Results
Our pooled results showed that patients directly admitted to CSCs had higher chances of achieving a favorable functional outcome at 3 months than those secondarily transferred to CSCs (OR = 1.26; 95% CI, 1.12–1.42; P < 0.001). In addition, no significant difference was found between the two transportation paradigms in the rate of sICH (OR = 0.86; 95% CI, 0.62–1.18; P = 0.35), mortality in hospital (OR = 0.84; 95% CI, 0.51–1.39; P = 0.51), mortality at 3 months (OR = 1.01; 95% CI, 0.85–1.21; P = 0.91), and successful recanalization (OR = 1.03; 95% CI, 0.88–1.20; P = 0.74). However, in the 100% bridging thrombolysis usage rate subgroup, our subgroup analysis indicated that no difference was found in any outcome between the two transportation paradigms.
Conclusion
Patients with AIS directly admitted to CSCs for MT may be a feasible transportation paradigm for AIS patients. However, more large-scale randomized prospective trials are required to further investigate this issue.
Similar content being viewed by others
References
Berkhemer OA et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. New England J Med 372:11–20. https://doi.org/10.1056/NEJMoa1411587
Campbell BCV et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. New England J Med 372:1009–1018. https://doi.org/10.1056/NEJMoa1414792
Goyal M et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. New England J Med 372:1019–1030. https://doi.org/10.1056/NEJMoa1414905
Saver JL et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England J Med 372:2285–2295. https://doi.org/10.1056/NEJMoa1415061
Jovin TG et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. New England J Med 372:2296–2306. https://doi.org/10.1056/NEJMoa1503780
Goyal M et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet (London, England) 387:1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-X
Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097. https://doi.org/10.1371/journal.pmed.1000097
Adams KM et al (2019) Outcomes after Thrombectomy in Belfast: Mothership and Drip-and-Ship in the Real World. Cerebrovasc Dis 47:231–237. https://doi.org/10.1159/000500849
Asaithambi G et al (2018) Real-world treatment of large vessel occlusions: combined outcomes of directly presenting and transferred-in patients to a stroke center. Neurol Res 40:637–643. https://doi.org/10.1080/01616412.2018.1460700
Barlinn J et al (2017) Acute endovascular treatment delivery to ischemic stroke patients transferred within a telestroke network: a retrospective observational study. Int J Stroke 12:502–509. https://doi.org/10.1177/1747493016681018
Bücke P et al (2018) Endovascular Thrombectomy in Acute Ischemic Stroke: Outcome in Referred Versus Directly Admitted Patients. Clin Neuroradiol 28:235–244. https://doi.org/10.1007/s00062-017-0558-z
Feil K et al (2020) Drip and ship for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria. Neurology 94:e453–e463. https://doi.org/10.1212/WNL.0000000000008753
Froehler MT et al (2017) 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). Circulation 136:2311–2321. https://doi.org/10.1161/circulationaha.117.028920
Gerschenfeld G et al (2017) Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke. JAMA Neurol 74:549–556. https://doi.org/10.1001/jamaneurol.2016.5823
Hiyama N et al (2016) Safety and effectiveness of drip, ship, and retrieve paradigm for acute ischemic stroke: A single center experience. Neurol Med Chir 56:731–736. https://doi.org/10.2176/nmc.oa.2016-0102
Jayaraman MV et al (2020) Field triage for endovascular stroke therapy: a population-based comparison. J Neurointervent Surg 12:233–239. https://doi.org/10.1136/neurintsurg-2019-015033
Drip PMS et al (2016) ship, and on-demand endovascular therapy for acute ischemic stroke. PLoS ONE. https://doi.org/10.1371/journal.pone.0150668
Prothmann S et al (2017) Acute Recanalization of Thrombo-Embolic Ischemic Stroke with pREset (ARTESp): the impact of occlusion time on clinical outcome of directly admitted and transferred patients. J Neurointervent Surg 9:817–822. https://doi.org/10.1136/neurintsurg-2016-012556
Rinaldo L et al (2017) Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke. J Neurointervent Surg 9:1166–1172. https://doi.org/10.1136/neurintsurg-2016-012824
Sarraj A et al (2019) Outcomes of thrombectomy in transferred patients with ischemic stroke in the late window: A subanalysis from the defuse 3 trial. JAMA Neurol 76:682–689. https://doi.org/10.1001/jamaneurol.2019.0118
Seker F et al (2019) Direct Admission vs. Secondary Transfer to a Comprehensive Stroke Center for Thrombectomy: Retrospective Analysis of a Regional Stroke Registry with 2797 Patients. Clin Neuroradiol. https://doi.org/10.1007/s00062-019-00842-9
Shigeta K et al (2019) Widening time disparities between two paradigms: tama-registry of acute endovascular thrombectomy. J Stroke Cerebrovascular Dis 28:1267–1273. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.01.021
Van Veenendaal P et al (2018) Endovascular clot retrieval by hub-and-spoke service delivery is feasible compared with direct-to-mothership. Cerebrovasc Dis 46:170–175. https://doi.org/10.1159/000490421
Weber R et al (2016) Outcome and periprocedural time management in referred versus directly admitted stroke patients treated with thrombectomy. Therapeut Adv Neurol Dis 9:79–84. https://doi.org/10.1177/1756285615617081
Weisenburger-Lile D et al (2019) Direct admission versus secondary transfer for acute stroke patients treated with intravenous thrombolysis and thrombectomy: Insights from the endovascular treatment in ischemic stroke registry. Cerebrovasc Dis 47:112–120. https://doi.org/10.1159/000499112
Saver JL et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs t-PA alone in stroke. New England J Med 372:2285–2295. https://doi.org/10.1056/NEJMoa1415061
Mansoor S, Zand R, Al-Wafai A, Wahba MN, Giraldo EA (2013) Safety of a "drip and ship" intravenous thrombolysis protocol for patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 22:969–971. https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.12.010
Qureshi AI et al (2012) Outcome of the 'Drip-and-Ship' Paradigm among Patients with Acute Ischemic Stroke: Results of a Statewide Study. Cerebrovasc Diseases Extra 2:1–8
Silverman IE, Beland DK, Chhabra J, McCullough LD (2005) The, "drip-and-ship" approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 69:613–620
Tekle WG et al (2012) Drip-and-ship thrombolytic treatment paradigm among acute ischemic stroke patients in the United States. Stroke 43:1971–1974. https://doi.org/10.1161/STROKEAHA.112.657817
Saver JL et al (2016) Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA 316:1279–1288. https://doi.org/10.1001/jama.2016.13647
Goyal M et al (2016) Analysis of Workflow and Time to Treatment and the Effects on Outcome in Endovascular Treatment of Acute Ischemic Stroke: Results from the SWIFT PRIME Randomized Controlled Trial. Radiology 279:888–897. https://doi.org/10.1148/radiol.2016160204
Fan L et al (2020) Outcomes of mechanical thrombectomy with pre-intravenous thrombolysis: a systematic review and meta-analysis. J Neurol. https://doi.org/10.1007/s00415-020-09778-4
Mistry EA et al (2017) Mechanical Thrombectomy Outcomes With and Without Intravenous Thrombolysis in Stroke Patients: A Meta-Analysis. Stroke 48:2450–2456. https://doi.org/10.1161/STROKEAHA.117.017320
Broeg-Morvay A et al (2016) Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis. Stroke 47:1037–1044. https://doi.org/10.1161/STROKEAHA.115.011134
Whiteley WN et al (2016) Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 15:925–933. https://doi.org/10.1016/s1474-4422(16)30076-x
Lees KR et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375:1695–1703. https://doi.org/10.1016/s0140-6736(10)60491-6
Jansen IGH, Mulder M, Goldhoorn RB (2018) Endovascular treatment for acute ischaemic stroke in routine clinical practice: prospective, observational cohort study (MR CLEAN Registry). BMJ Clin Res. https://doi.org/10.1136/bmj.k949
van Meenen LCC et al (2020) Interhospital transfer vs direct presentation of patients with a large vessel occlusion not eligible for IV thrombolysis. J Neurol. https://doi.org/10.1007/s00415-020-09812-5
Rodríguez-Pardo J et al (2020) Prehospital selection of thrombectomy candidates beyond large vessel occlusion: M-DIRECT scale. Neurology. https://doi.org/10.1212/WNL.0000000000008998
Turc G (2017) Mothership or drip-and-ship in the era of thrombectomy: can we use prehospital clinical scales as a compass? Eur J Neurol 24:543–544. https://doi.org/10.1111/ene.13261
Acknowledgements
None.
Funding
None.
Author information
Authors and Affiliations
Contributions
Weisong Zhao and Pengju Ma: literature search, data analysis, interpretation of the data, drafting and revision of the manuscript. Jinbao Chen: data analysis, interpretation of the data. Xuejing Yue: interpretation of the data, and critical revision of the manuscript.
Corresponding author
Ethics declarations
Conflicts of interest
None declared.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Zhao, W., Ma, P., Chen, J. et al. Direct admission versus secondary transfer for acute ischemic stroke patients treated with thrombectomy: a systematic review and meta-analysis. J Neurol 268, 3601–3609 (2021). https://doi.org/10.1007/s00415-020-09877-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-020-09877-2