Large Vessel Occlusion Stroke

Prehospital Comprehensive Stroke Center or Primary Stroke Center Triage: Which One is Better For Patients With Suspected Large Vessel Occlusion Stroke

New findings suggest that implementation of a regional prehospital transport policy for comprehensive stroke center triage may result in a significant increase in EVT rates in patients with acute ischemic stroke and large vessel occlusion

Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether the implementation of a regional prehospital transport policy for comprehensive stroke center triage increases the uses of EVT is uncertain. A new study evaluates the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT.

This retrospective, the multicenter pre-implementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions are prehospital EMS transport policy to triage patients with suspected large vessel occlusion stroke, using a 3-item stroke scale, to comprehensive stroke centers.

Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the pre-implementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (pre-implementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (pre-implementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to the 24-hour window or by interhospital transfer or walk-in, irrespective of the time window.

Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.

Source: JAMA Neurology

Image: WAMU