Advertisement

Direct Admission vs. Secondary Transfer to a Comprehensive Stroke Center for Thrombectomy

Retrospective Analysis of a Regional Stroke Registry with 2797 Patients
  • Fatih Seker
  • Susanne Bonekamp
  • Susanne Rode
  • Sonja Hyrenbach
  • Martin Bendszus
  • Markus A. MöhlenbruchEmail author
Original Article
  • 21 Downloads

Abstract

Background and Purpose

This study aimed at comparing short-term clinical outcome after thrombectomy in patients directly admitted (DA) to a comprehensive stroke center with patients secondarily transferred (ST) from a primary stroke center.

Methods

In a prospective regional stroke registry, all stroke patients with a premorbid modified Rankin scale (mRS) score 0–2 who were admitted within 24 h after stroke onset and treated with thrombectomy between 2014 and 2017 were retrospectively analyzed. Patients with DA and ST were compared regarding the proportion of good outcome (discharge mRS 0–2), median discharge mRS, mRS shift (difference between premorbid mRS and mRS on discharge) and occurrence of symptomatic intracranial hemorrhage.

Results

Out of 2797 patients, 1051 (37.6%) achieved good clinical outcome. In the DA group (n = 1657), proportion of good outcome was higher (DA 42.2% vs. ST 30.9%, P < 0.001) and median discharge mRS (DA 3 vs. ST 4, P < 0.001) and median mRS shift (DA 3 vs. ST 4, P < 0.001) were lower. The rate of symptomatic intracranial hemorrhage was similar in both groups (DA 9.3% vs. ST 7.5%, P = 0.101). Multivariate analysis revealed that direct admission was an independent predictor of good clinical outcome (adjusted odds ratio, OR 1.32, confidence interval, CI 1.09–1.60, P = 0.004).

Conclusion

These results confirm prior studies stating that DA to a comprehensive stroke center leads to better outcome compared to ST in stroke patients undergoing thrombectomy.

Keywords

Mothership Drip and Ship Triage Regional stroke care Interhospital transfer 

Abbreviations

CSC

Comprehensive stroke center

DA

Direct admission

EVT

Endovascular thrombectomy

IVT

Intravenous thrombolysis

ST

Secondary transfer

Notes

Author Contribution

F. Seker, S. Bonekamp, M. Bendszus and M.A. Möhlenbruch conceived the study and initiated the study design. S. Hyrenbach and S. Rode contributed to acquisition of data. F. Seker, M. Bendszus and M.A. Möhlenbruch contributed to analysis and interpretation of data. All authors contributed to refinement of the study protocol and reviewed and approved the final manuscript.

Conflict of interest

F. Seker, S. Bonekamp, S. Rode, S. Hyrenbach, M. Bendszus and M.A. Möhlenbruch declare that they have no competing interests.

References

  1. 1.
    Caplan LR. Primary stroke centers vs comprehensive stroke centers with Interventional capabilities: which is better for a patient with suspected stroke? JAMA Neurol. 2017;74:504–6.CrossRefGoogle Scholar
  2. 2.
    Fiehler J. Mothership or drip and ship? Radiologe. 2019;59:610–5.CrossRefGoogle Scholar
  3. 3.
    Krogias C, Bartig D, Kitzrow M, Brassel F, Busch EW, Nolden-Koch M, et al. Verfügbarkeit der mechanischen Thrombektomie bei akutem Hirninfarkt. Nervenarzt. 2017;88:1177–85.CrossRefGoogle Scholar
  4. 4.
    Berlis A, Morhard D, Weber W. Flächendeckende Versorgung des akuten Schlaganfalls im Jahr 2016 und 2017 durch Neuro-Radiologen mittels mechanischer Thrombektomie in Deutschland anhand des DeGIR/DGNR-Registers. Röfo. 2019;191:613–7.PubMedGoogle Scholar
  5. 5.
    Park MS, Yoon W, Kim JT, Choi KH, Kang SH, Kim BC, et al. Drip, ship, and on-demand Endovascular therapy for acute Ischemic stroke. PLoS ONE. 2016;11:e150668.CrossRefGoogle Scholar
  6. 6.
    Prothmann S, Schwaiger BJ, Gersing AS, Reith W, Niederstadt T, Felber A, et al. 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 Neurointerv Surg. 2017;9:817–22.CrossRefGoogle Scholar
  7. 7.
    Bücke P, Pérez MA, Schmid E, Nolte CH, Bäzner H, Henkes H. Endovascular Thrombectomy in acute Ischemic stroke: outcome in referred versus directly admitted patients. Clin Neuroradiol. 2018;28:235–44.CrossRefGoogle Scholar
  8. 8.
    Pfaff J, Pham M, Herweh C, Wolf M, Ringleb PA, Schönenberger S, et al. Clinical outcome after mechanical thrombectomy in non-elderly patients with acute Ischemic stroke in the anterior circulation: primary admission versus patients referred from remote hospitals. Clin Neuroradiol. 2017;27:185–92.CrossRefGoogle Scholar
  9. 9.
    Mokin M, Gupta R, Guerrero WR, Rose DZ, Burgin WS, Sivakanthan S. ASPECTS decay during inter-facility transfer in patients with large vessel occlusion strokes. J Neurointerv Surg. 2017;9:442–4.CrossRefGoogle Scholar
  10. 10.
    Ismail M, Armoiry X, Tau N, Zhu F, Sadeh-Gonik U, Piotin M, et al. Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis. J Neurointerv Surg. 2019;11:14–9.CrossRefGoogle Scholar
  11. 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;372:2285–95.CrossRefGoogle Scholar
  12. 12.
    Weber R, Reimann G, Weimar C, Winkler A, Berger K, Nordmeyer H, et al. Outcome and periprocedural time management in referred versus directly admitted stroke patients treated with thrombectomy. Ther Adv Neurol Disord. 2016;9:79–84.CrossRefGoogle Scholar
  13. 13.
    Rinaldo L, Brinjikji W, McCutcheon BA, Bydon M, Cloft H, Kallmes DF, et al. Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke. J Neurointerv Surg. 2017;9:1166–72.CrossRefGoogle Scholar
  14. 14.
    Gerschenfeld G, Muresan IP, Blanc R, Obadia M, Abrivard M, Piotin M, et al. Two paradigms for endovascular thrombectomy after intravenous thrombolysis for acute ischemic stroke. JAMA Neurol. 2017;74:549–56.CrossRefGoogle Scholar
  15. 15.
    Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznik RP, et al. 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. 2017;136:2311–21.CrossRefGoogle Scholar
  16. 16.
    Weisenburger-Lile D, Blanc R, Kyheng M, Desilles JP, Labreuche J, Piotin M, et al. 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. 2019;47:112–20.  https://doi.org/10.1159/000499112 CrossRefPubMedGoogle Scholar
  17. 17.
    Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42:1775–7.CrossRefGoogle Scholar
  18. 18.
    Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.CrossRefGoogle Scholar
  19. 19.
    Purrucker JC, Härtig F, Richter H, Engelbrecht A, Hartmann J, Auer J, et al. Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH Stroke Scale for emergency medical services. BMJ Open. 2017;7:e16893.CrossRefGoogle Scholar
  20. 20.
    Connolly F, Röhl JE, Guthke C, Wengert O, Valdueza JM, Schreiber SJ. Emergency room use of “fast-track” ultrasound in acute stroke: an observational study. Ultrasound Med Biol. 2019;45:1103–11.CrossRefGoogle Scholar
  21. 21.
    Menon BK, Sajobi TT, Zhang Y, Rempel JL, Shuaib A, Thornton J, et al. Analysis of workflow and time to treatment on thrombectomy outcome in the ESCAPE randomized controlled trial. Circulation. 2016;133:2279–86.CrossRefGoogle Scholar
  22. 22.
    Ng FC, Low E, Andrew E, Smith K, Campbell BCV, Hand PJ, et al. Deconstruction of Interhospital transfer workflow in large vessel occlusion. Stroke. 2017;48:1976–9.CrossRefGoogle Scholar
  23. 23.
    Hui FK, El Mekabaty A, Schultz J, Hong K, Horton K, Urrutia V, et al. Helistroke: neurointerventionalist helicopter transport for interventional stroke treatment: proof of concept and rationale. J Neurointerv Surg. 2018;10:225–8.CrossRefGoogle Scholar
  24. 24.
    Wei D, Oxley TJ, Nistal DA, Mascitelli JR, Wilson N, Stein L, et al. Mobile interventional stroke teams lead to faster treatment times for thrombectomy in large vessel occlusion. Stroke. 2017;48:3295–300.CrossRefGoogle Scholar
  25. 25.
    Brekenfeld C, Goebell E, Schmidt H, Henningsen H, Kraemer C, Tebben J, et al. ‘Drip-and-drive’: shipping the neurointerventionalist to provide mechanical thrombectomy in primary stroke centers. J Neurointerv Surg. 2018;10:932–6.CrossRefGoogle Scholar
  26. 26.
    Seker F, Möhlenbruch MA, Nagel S, Ulfert C, Schönenberger S, Pfaff J, et al. Clinical results of a new concept of neurothrombectomy coverage at a remote hospital—“drive the doctor”. Int J Stroke. 2018;13:696–9.CrossRefGoogle Scholar
  27. 27.
    Ovbiagele B, Saver JL. Day-90 acute Ischemic stroke outcomes can be derived from early functional activity level. Cerebrovasc Dis. 2010;29:50–6.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeuroradiologyHeidelberg University HospitalHeidelbergGermany
  2. 2.Qualitätssicherung im Gesundheitswesen Baden-Württemberg GmbHStuttgartGermany

Personalised recommendations