Abstract
Introduction
Prehospital stroke endovascular therapy bypass transports patients with suspected large vessel occlusion directly to an endovascular therapy capable center. Our objective was to determine if an endovascular therapy bypass protocol improved access to stroke treatments. Secondary objectives were to determine safety, effectiveness, and rate of subsequent interfacility transfers.
Methods
Endovascular therapy bypass in 2018 was implemented in Eastern Ontario, for patients with a Los-Angeles-Motor-Scale ≥ 4 (positive large vessel occlusion screen) with a 90-min transport time if < 6 h from last seen well. A before–after health record review was conducted from Dec 1, 2017 to Nov 30, 2019. A piloted data form was used to extract demographics, times, primary outcomes (endovascular therapy and intravenous (IV) tissue plasminogen activator (tPA) rate), and secondary outcomes (redirect to closer hospital, airway intervention, and subsequent interfacility transfer). We present descriptive statistics and odds ratios (OR) with 95% confidence intervals (CI) from multivariable logistic regression.
Results
We included 379 stroke patients (165 pre and 214 post-implementation). The endovascular therapy rate between groups was similar (14.1% vs 15.1%). The bypass had an OR of 0.98 (95% CI 0.54–1.78) for receiving endovascular therapy. IV tPA was given to 25.4% of patients pre vs 27.4% post-implementation (OR 1.06, 95% CI 0.65–1.74). No patients became unstable during transport, only one patient had an intubation attempt. The inappropriate bypass (false positive) rate was 12.7% pre vs 12.8% post-implementation (positive predictive value 87%). The bypass protocol had an OR of 1.06 (95% CI 0.58–1.95) for subsequent interfacility transfer with a mean of 2.7 h at the community site before transfer.
Conclusions
Endovascular therapy stroke bypass with 90-min transport radius and Los-Angeles-Motor-Scale ≥ 4 was safe and well executed by paramedics. Our study did not show any difference in endovascular therapy rate from its implementation. The IV tPA rate was similar between groups despite potentially bypassing thrombolysis capable centers.
Abstrait
Introduction
Le pontage de la thérapie endovasculaire pré-hospitalière transporte les patients présentant une occlusion suspectée de gros vaisseaux directement vers un centre capable de thérapie endovasculaire. Notre objectif était de déterminer si un protocole de pontage endovasculaire améliore l’accès aux traitements d’AVC. Les objectifs secondaires étaient de déterminer l’innocuité, l’efficacité et le taux des transferts d’interfacilité subséquents.
Méthodes
Le pontage par thérapie endovasculaire en 2018 a été mis en œuvre dans l’Est de l’Ontario, pour les patients ayant un test Los-Angeles-Motor-Scale 4 (test positif d’occlusion des gros vaisseaux) avec un temps de transport de 90 minutes si < 6 heures après la dernière observation. Un examen du dossier de santé avant-après a été effectué du 1er décembre 2017 au 30 novembre 2019. Un formulaire de données pilote a été utilisé pour extraire les données démographiques, les heures, les résultats primaires (traitement endovasculaire et taux d’activation du plasminogène par voie intraveineuse (IV) et les résultats secondaires (réorientation vers un hôpital plus proche, intervention sur les voies respiratoires et transfert d’interfacilité subséquent). Nous présentons des statistiques descriptives et des rapports de cotes (RC) avec des intervalles de confiance (IC) à 95 % à partir d’une régression logistique multivariée.
Résultats
Nous avons inclus 379 AVC (165 avant et 214 après la mise en œuvre). Le taux de traitement endovasculaire entre les groupes était similaire (14,1 % vs 15,1 %). Le pontage avait un RC de 0,98 (IC à 95 %, 0,54-1,78) pour le traitement endovasculaire. Le tPA IV a été administré à 25,4% des patients avant vs 27,4% après la mise en œuvre (OR 1,06, 95%CI 0,65-1,74). Aucun patient n’est devenu instable pendant le transport, seulement 1 patient a eu une tentative d’intubation. Le taux de pontage inapproprié (faux positif) était de 12,7 % avant et de 12,8 % après la mise en œuvre (valeur prédictive positive de 87 %). Le protocole de contournement avait un RC de 1,06 (IC à 95 % 0,58-1,95) pour le transfert d’interfacilité ultérieur avec une moyenne de 2,7 heures sur le site de la communauté avant le transfert.
Conclusions
Le pontage d’AVC de thérapie endovasculaire avec un rayon de transport de 90 minutes et Los-Angeles-Motor-Scale 4 était sûr et bien exécuté par les ambulanciers. Notre étude n’a montré aucune différence dans le taux de thérapie endovasculaire par rapport à sa mise en œuvre. Le taux de tPA IV était similaire entre les groupes malgré le fait que les centres capables de contourner la thrombolyse étaient potentiellement contournés.
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References
Goyal M, Ospel JM. Stroke systems of care: current state of affairs and future directions. Stroke. 2020;51(7):1928–31.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.
Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.
Berkhemer O, Fransen P, Beumer D, van der Berg L, Lingsma H, Yoo A, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014;372(1):11–20.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):1–11.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.
Campbell BCV, Donnan GA, Lees KR, Hacke W, Khatri P, Hill MD, et al. Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol. 2015;14(8):846–54.
Bosson N, Gausche-Hill M, Saver JL, Sanossian N, Tadeo R, Clare C, et al. Increased access to and use of endovascular therapy following implementation of a 2-tiered regional stroke system. Stroke. 2020;51:908–13.
Almekhlafi MA, Holodinsky JK, Hill MD, Kamal N, Goyal M. Organizing stroke systems in the field for patients with suspected large vessel occlusion acute stroke. Expert Rev Cardiovasc Ther. 2019;17(1):3–9.
Fifi JT, Dabus G, Mack WJ, Mocco J, Pride L, Arthur AS, et al. In the thrombectomy era, triage in the field improves care. J NeuroIntervent Surg. 2018;10(7):607–8.
Smith EE, Kent DM, Bulsara KR, Leung LY, Lichtman JH, Reeves MJ, et al. Accuracy of prediction instruments for diagnosing large vessel occlusion in individuals with suspected stroke: a systematic review for the 2018 guidelines for the early management of patients with acute ischemic stroke. Stroke. 2018;49(3):e111–22.
Nazliel B, Starkman S, Liebeskind DS, Ovbiagele B, Kim D, Sanossian N, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke. 2008;39(8):2264–7.
Boulanger JM, Butcher K, Gubitz G, G S, Smith EE, Lindsay MP,. Canadian stroke best practice recommendations acute stroke management: update 2018. Toronto: Heart and Stroke Foundation; 2018.
Holodinsky JK, Williamson TS, Demchuk AM, Zhao H, Zhu L, Francis MJ, et al. Modeling stroke patient transport for all patients with suspected large-vessel occlusion. JAMA Neurol. 2018;75(12):1477–86.
Shigeta K, Ota T, Amano T, Ueda M, Matsumaru Y, Shiokawa Y, et al. Widening time disparities between two paradigms: tama-REgistry of acute endovascular thrombectomy. J Stroke Cerebrovasc Dis. 2019;28(5):1267–73.
Mohamed GA, Marmarchi F, Fonkeu Y, Alshaer Q, Rangaraju S, Carr M, et al. Cincinnati prehospital stroke scale implementation of an urban county severity-based stroke triage protocol: Impact and outcomes on a comprehensive stroke center. J Stroke Cerebrovasc Dis. 2022;31(8): 106575.
Keselman B, Berglund A, Ahmed N, Bottai M, von Euler M, Holmin S, et al. The stockholm stroke triage project: outcomes of endovascular thrombectomy before and after triage implementation. Stroke. 2022;53(2):473–81.
Emergency Health Regulatory and Accountability Branch Ministry of Health. Advanced life support patient care standards.
Almqvist T, Berglund A, Sjöstrand C, Eriksson E, Mazya MV. Prehospital triage accuracy in patients with stroke symptoms assessed within 6 to 24 hours or with an unknown time of onset. Stroke. 2021;52(4):1441–5.
Mazya MV, Berglund A, Ahmed N, von Euler M, Holmin S, Laska AC, et al. Implementation of a prehospital stroke triage system using symptom severity and teleconsultation in the stockholm stroke triage study. JAMA Neurol. 2020;77(6):691.
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Mitchell, S., Pinnell, R., McMahon, E. et al. Evaluation of a prehospital endovascular therapy stroke bypass program. Can J Emerg Med (2024). https://doi.org/10.1007/s43678-024-00685-5
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DOI: https://doi.org/10.1007/s43678-024-00685-5