Optimizing Time Management for Drip-and-Ship Stroke Patients Qualifying for Endovascular Therapy-A Single-Network Study.

BACKGROUND: We sought to identify factors for delayed drip-and-ship (DS) management in stroke patients transferred from primary hospitals to our comprehensive stroke center (CSC) for endovascular therapy (EVT). METHODS: We conducted a retrospective study of all patients transferred to our CSC for EVT between 2016 and 2020. We analyzed emergency and hospital records to assess DS process times and factors predictive of delays. We dichotomized the admission period to 2016−2017 and 2018−2020 according to the main process optimization, including the introduction of a prenotification call. RESULTS: We included 869 DS patients (median age 76 years (IQR 65−82), NIHSS 16 (IQR 11−21), 278 min (IQR 243−335) from onset to EVT); 566 were transferred in 2018−2020. Admission in 2016−2017, during on-call, longer tranfer distance, and general anesthesia were factors independently associated with delayed onset to EVT time (F(5, 352) = 14.76, p < 0.000). Other factors associated with delayed DS management were: transfer mode, primary hospital type, site of large-vessel occlusion, and intravenous thrombolysis. Total transfer time was faster for distances <50 km by ambulance and for distances >71 km by helicopter. CONCLUSION: Assessment of DS processes and times throughout the patient pathway allows identification of potentially modifiable factors for improvement of the very time-critical workflow for stroke patients.

Association of Regular Thrombus Surface Phenotype With Complete Recanalization in First-Line Contact Aspiration Thrombectomy for Basilar Artery Occlusion.

Objective: To assess whether angiographic thrombus surface phenotype has an impact on efficacy of contact aspiration (CA) thrombectomy in patients with basilar artery occlusion (BAO). Methods: From January 2016 to December 2019, consecutive stroke patients with a BAO and first-line CA were analyzed in this retrospective study. We assessed baseline and imaging characteristics and treatment and clinical outcomes. We rated thrombus surface phenotype on pre-treatment digital subtraction angiography in a three-reader-consensus setting. Primary outcome was complete recanalization (modified treatment in cerebral ischemia [mTICI] 3 and arterial occlusive lesion [AOL] 3) after first-line CA without additionally stent retriever passes. Data analysis was stratified according to thrombus surface phenotype and complete first-line recanalization. Results: Seventy-eight patients met the inclusion criteria. Median age was 74 years (IQR 64-80), 64% were male, and median baseline NIHSS score was 24 (IQR 7-32). Thirty patients had a regular and 16 patients had an irregular thrombus phenotype. Thrombus surface was not assessable in 32 patients. In patients with a regular phenotype, complete recanalization was more often achieved compared to irregular and non-ratable phenotypes (50 vs. 18.8% and 21.9%; p = 0.027). Patients with a regular phenotype [odds ratio [OR] 8.3; 95% confidence interval [CI]: 1.9-35.8; p = 0.005], cardioembolic stroke (OR 12.1, 95% CI: 2.0-72.8; p = 0.007), and proximal end of the thrombus in the middle basilar artery segment (OR 5.2, 95% CI: 1.0-26.6; p = 0.046) were more likely to achieve complete recanalization after first-line CA without rescue therapy. Conclusion: The efficacy of CA may differ according to the angiographic thrombus surface phenotype in patients with BAO. A regular phenotype is associated with higher rates of complete recanalization in first-line CA. However, assessment of thrombus phenotype is frequently not feasible in BAO.

Impact of thrombus surface on first pass reperfusion in contact aspiration and stent retriever thrombectomy.

BACKGROUND: To assess whether thrombus surface morphology has an impact on first pass reperfusion in contact aspiration (CA) and stent retriever (SR) thrombectomy. METHODS: From January 2016 to December 2018, consecutive stroke patients with an occlusion of the middle cerebral artery and thrombectomy (CA or SR) were examined in this retrospective study. We assessed patients' characteristics, procedural data and clinical outcome. Thrombus surface on pretreatment digital subtraction angiography (DSA) was categorized into regular versus irregular phenotype by blinded three-reader-consensus. Primary outcome was successful reperfusion (modified treatment in cerebral ischemia (mTICI) 2b-3) after first pass. Data analysis was stratified according to thrombectomy technique and thrombus phenotype. RESULTS: Among 203 patients (76 years (IQR 65.5-81.9), 47.3% male, National Institutes of Health Stroke Scale Score 16 (IQR 12-20)), 155 patients were treated primarily with CA and 48 with SR. 40% (n=62/155) CA and 41.7% (n=20/48) SR-treated patients had a regular thrombus phenotype. In the CA group, successful reperfusion after first pass was more frequently obtained in patients with regular compared with irregular phenotype (69.4% (n=43/62) vs 34.4% (n=32/93); P<0.0001). In contrast, in the SR group, reperfusion after first pass was achieved in 35% (n=7/20; P=0.01) of patients with regular phenotypes. In the CA group, median number of passes (1 (1-2) vs 2 (1-4); P<0.00001) and time from reaching the thrombus to reperfusion (19±27 vs 38±36 min; P=0.0001) were lower among patients with a regular phenotype. CONCLUSION: Direct CA is associated with higher rates of successful first pass reperfusion in patients with a regular thrombus phenotype in pretreatment DSA.

Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy.

Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT. Methods: We analyzed data from our prospective database (01/2016-02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (-EVT-Call) and after (+EVT-Call) implementation of the EVT-Call. Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65-81], NIHSS score 17 [12-22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14-22] vs. 10 min [7-13]; p < 0.001), image-to-groin time (54 min [43.5-69.25] vs. 47 min [38.3-58.75]; p = 0.042) and door-to-groin time (74 min [58-86.5] vs. 60 min [49.3-71]; p < 0.001) were reduced after implementation of the EVT-Call. Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.