Optimizing Systems of Care for Endovascular Thrombectomy in Ischemic Stroke
2017; Lippincott Williams & Wilkins; Volume: 136; Issue: 24 Linguagem: Inglês
10.1161/circulationaha.117.031444
ISSN1524-4539
AutoresBruce Campbell, Geoffrey A. Donnan, Stephen M. Davis,
Tópico(s)Stroke Rehabilitation and Recovery
ResumoHomeCirculationVol. 136, No. 24Optimizing Systems of Care for Endovascular Thrombectomy in Ischemic Stroke Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBOptimizing Systems of Care for Endovascular Thrombectomy in Ischemic StrokeDrip and Ship Versus Mothership Bruce C.V. Campbell, PhD, Geoffrey A. Donnan, MD and Stephen M. Davis, MD Bruce C.V. CampbellBruce C.V. Campbell Melbourne Brain Centre and Departments of Medicine and Neurology, Royal Melbourne Hospital, Parkville, Australia (B.C.V.C., S.M.D.). Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (B.C.V.C., S.M.D., G.A.D.). , Geoffrey A. DonnanGeoffrey A. Donnan Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (B.C.V.C., S.M.D., G.A.D.). and Stephen M. DavisStephen M. Davis Melbourne Brain Centre and Departments of Medicine and Neurology, Royal Melbourne Hospital, Parkville, Australia (B.C.V.C., S.M.D.). Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (B.C.V.C., S.M.D., G.A.D.). Originally published12 Dec 2017https://doi.org/10.1161/CIRCULATIONAHA.117.031444Circulation. 2017;136:2322–2324Articles, see p 2303 and p 2311In this issue of Circulation, Smith and colleagues1 report the impressive uptake in endovascular thrombectomy for ischemic stroke in the United States since the publication of positive randomized trials in 2015. However, there is substantial capacity to further increase the proportion of patients treated. This relates mainly to the structure of the healthcare system that has contributed to variable uptake of endovascular therapy globally, even within developed countries. Smith et al found an almost 2-fold variation in rates of endovascular thrombectomy between states in the United States. The crucial impact of systems of care is also highlighted by Froehler and colleagues,2 who present data from the STRATIS registry (Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke) demonstrating substantially worse outcomes in patients requiring interhospital transfer to access endovascular thrombectomy, directly linked to delayed time to revascularization.The proportion of patients with ischemic stroke eligible for endovascular thrombectomy is currently unknown, and clinicians' perceptions of eligibility continue to evolve with new evidence and greater familiarity. The HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) individual patient data meta-analysis demonstrated benefit across a broad range of clinical and imaging subgroups3 that extend well beyond the current American Heart Association/American Stroke Association Class 1 recommendation.4 Large vessel occlusion (LVO) status is not recorded in the Get With The Guidelines database, so Smith and colleagues used a construct of "potentially eligible" patients, defined as arrival 4 times the proportion treated when all hospitals in the Get With The Guidelines database were considered (3.3%). The true proportion of patients currently treated is likely to be lower still in hospitals not participating in the registry.The key findings from the STRATIS registry were that patients who required interhospital transfer for thrombectomy achieved reperfusion a median 109 minutes later than direct presenters and had an ≈8% lower absolute probability of independent outcome. These data are consistent with results from the HERMES meta-analysis, in which onset to reperfusion time was 2 hours longer in patients requiring interhospital transfer,6 and real-world data from Melbourne, Australia, which also showed a 2-hour delay related to interhospital transfers.9 No data were available in STRATIS on the proportion of patients referred for treatment by nonendovascular hospitals compared with endovascular-capable hospitals. However, the Get With The Guidelines data suggest that there is substantial attrition in the proportion of potentially eligible patients actually treated among those who do not present directly to an endovascular-capable center. The combined effect of fewer patients receiving treatment and worse outcomes in those who are treated is that the true outcomes for patients with LVO presenting to nonendovascular capable hospitals are likely to be substantially worse than indicated by STRATIS.These data demand a substantial change in the way we manage stroke. There may be lessons from the transition to endovascular procedures in cardiology in previous decades. However, the incidence of ST-segment–elevation myocardial infarction10 is >3 times that of LVO ischemic stroke. Percutaneous coronary intervention generally also has fewer technical challenges in vascular access and potential complications. It is therefore unlikely that uncontrolled proliferation of endovascular-capable centers is the best option for service delivery. Procedural volume and patient outcomes are clearly related,11 which favors a concentration of expertise at centers that are deliberately located to provide optimal geographic coverage. This central control of health system delivery is uncommon, particularly in the United States, but has been achieved for trauma, which may act as a useful precedent when lobbying for change.There is much room for improvement in optimizing hub-and-spoke transfer networks through formalized protocols for eligibility, referral, and transfer and a reduction in "door-in door-out time."9 These approaches may minimize the referral attrition seen in Get With The Guidelines and the major delays leading to worse outcomes seen in transferred patients in STRATIS. Efficient use of brain imaging is one of the key elements in streamlined hub-and-spoke workflow. The positive endovascular trials all used computed tomography (CT) angiography (CTA) as an inclusion criterion. However, the current approach in many systems involves only noncontrast CT at the primary stroke center and transfer of patients with severe syndromes and hyperdense arteries. Definitive imaging then occurs on arrival at the endovascular-capable center, and if the neurointerventional team is activated only at that point, this introduces major delays in achieving reperfusion. It also leads to many futile transfers and, if activation does occur before imaging, unnecessary activations of the neurointerventional team. A more efficient approach is to immediately follow noncontrast CT with CTA of the arch to cerebral vertex at the initial hospital. Universal CT/CTA also identifies patients with LVO despite milder clinical symptoms who are at risk of subsequent clinical deterioration if untreated.12 Other benefits of routine CTA include making a positive diagnosis of stroke and identifying stroke mechanism. CTA is well within the hardware capability of contemporary CT scanners, and staff require minimal training. However, extra imaging at the initial hospital must not create undue delay, and the images must be immediately available for electronic review by the receiving stroke and neurointervention teams.The additional of CT perfusion has diagnostic benefits,13 provides additional confidence in telemedicine scenarios, and, on the basis of DAWN and DEFUSE 3, will be particularly critical for patients requiring long transfers that may put them outside 6 hours by the time of treatment. Definitive imaging at the initial hospital allows appropriate activation of the neurointervention team and reduces door-to-puncture time on arrival. In many cases, the patient can proceed directly to angiography without further cross-sectional imaging, unless there has been major clinical deterioration or an unexpectedly long transfer time.Although optimizing the existing hub-and-spoke networks is the simplest solution, the ideal approach to the system of care would involve recognition of LVO patients in the field and direct transport to an endovascular-capable center. Definitive LVO diagnosis before hospital arrival is enabled by CT-equipped mobile stroke units. These are increasing in number but are unlikely to form a widespread solution in the near future. There has been a proliferation of clinical triage scales that aim to allow bypass of patients with suspected LVO to an endovascular center. Although fairly sensitive to the diagnosis of LVO, the main challenge has been specificity, leading to the concern that patients who require only intravenous thrombolysis may receive delayed treatment as a result of bypassing their nearest hospital. The RACECAT randomized trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion; NCT02795962) is testing one of these clinical triage scales across the region of Catalonia in Spain. Some patients may be bypassed from regions with a 2-hour travel time to the nearest endovascular center, and the results are keenly awaited. However, the American Heart Association/American Stroke Association Mission: Lifeline program has already recommended that patients with severe stroke within 6 hours of stroke onset should be bypassed to an endovascular-capable hospital if this will incur no more than 15 minutes of additional travel time and not cause them to miss the thrombolysis treatment window.14It is reassuring that the hypothetical modeling from STRATIS indicated that the minimal thrombolysis delay with bypass to an endovascular center was greatly outweighed by faster times to revascularization. Furthermore, the added value of thrombolysis in patients who can be rapidly reperfused by endovascular thrombectomy is uncertain and being examined in clinical trials.Endovascular thrombectomy for ischemic stroke is an immensely powerful treatment to reduce disability for patients with the most severe strokes. The indications are continuing to expand, but it is already clear that a large group of potentially eligible patients are not accessing optimal treatment. Furthermore, system-related delays are compromising outcomes for those patients who do access endovascular thrombectomy. A system-wide, centralized effort will be required to optimally distribute resources, and stroke physicians will need to engage in the political process required to achieve re-engineering of the patient care pathway.15DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Bruce Campbell, PhD, Department of Neurology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia. E-mail [email protected]References1. Smith EE, Saver JL, Cox M, Liang L, Matsouaka R, Xian Y, Bhatt DL, Fonarow GC, Schwamm LH. Increase in endovascular therapy in Get With The Guidelines–Stroke after the publication of pivotal trials.Circulation. 2017; 136:2303–2310. doi: 10.1161/CIRCULATIONAHA.117.031097.LinkGoogle Scholar2. Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznick RP, Haussen DC, Hellinger FR, Yavagal DR, Yao TL, Liebeskind DS, Jadhav AP, Gupta R, Hassan AE, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti SR, Given CA, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Abou-Chebl A, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson DH, Kallmes DF, Baxter BW, Jumaa MA, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado Almandoz JE, Martin JC, Mueller-Kronast NH; STRATIS Investigators. 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; 136:2311–2321. doi: 10.1161/CIRCULATIONAHA.117.028920.LinkGoogle Scholar3. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES Collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387:1723–1731. doi: 10.1016/S0140-6736(16)00163-X.CrossrefMedlineGoogle Scholar4. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR; American Heart Association Stroke Council. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2015; 46:3020–3035. doi: 10.1161/STR.0000000000000074.LinkGoogle Scholar5. Vanacker P, Heldner MR, Amiguet M, Faouzi M, Cras P, Ntaios G, Arnold M, Mattle HP, Gralla J, Fischer U, Michel P. Prediction of large vessel occlusions in acute stroke: National Institute of Health Stroke Scale is hard to beat.Crit Care Med. 2016; 44:e336–e343. doi: 10.1097/CCM.0000000000001630.CrossrefMedlineGoogle Scholar6. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YB, Hill MD; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis.JAMA. 2016; 316:1279–1288. doi: 10.1001/jama.2016.13647.CrossrefMedlineGoogle Scholar7. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct [published online ahead of print November 11, 2017].N Engl J Med. http://www.nejm.org/doi/full/10.1056/NEJMoa1706442. doi: 10.1056/NEJMoa1706442.Google Scholar8. Chia NH, Leyden JM, Newbury J, Jannes J, Kleinig TJ. Determining the number of ischemic strokes potentially eligible for endovascular thrombectomy: a population-based study.Stroke. 2016; 47:1377–1380. doi: 10.1161/STROKEAHA.116.013165.LinkGoogle Scholar9. Ng FC, Low E, Andrew E, Smith K, Campbell BCV, Hand PJ, Crompton DE, Wijeratne T, Dewey HM, Choi PM. Deconstruction of interhospital transfer workflow in large vessel occlusion: real-world data in the thrombectomy era.Stroke. 2017; 48:1976–1979. doi: 10.1161/STROKEAHA.117.017235.LinkGoogle Scholar10. McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI.Am J Med. 2011; 124:40–47. doi: 10.1016/j.amjmed.2010.07.023.CrossrefMedlineGoogle Scholar11. Rinaldo L, Brinjikji W, Rabinstein AA. Transfer to high-volume centers associated with reduced mortality after endovascular treatment of acute stroke.Stroke. 2017; 48:1316–1321. doi: 10.1161/STROKEAHA.116.016360.LinkGoogle Scholar12. Coutts SB, Modi J, Patel SK, Demchuk AM, Goyal M, Hill MD; Calgary Stroke Program. CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study.Stroke. 2012; 43:1013–1017. doi: 10.1161/STROKEAHA.111.637421.LinkGoogle Scholar13. Campbell BC, Weir L, Desmond PM, Tu HT, Hand PJ, Yan B, Donnan GA, Parsons MW, Davis SM. CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke.J Neurol Neurosurg Psychiatry. 2013; 84:613–618. doi: 10.1136/jnnp-2012-303752.CrossrefMedlineGoogle Scholar14. Panagos P, Schwamm L. Mission: Lifeline: severity-based stroke triage algorithm for EMS. 2017https://www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_492025.pdf. Accessed September 12, 2017.Google Scholar15. Davis SM, Campbell BCV, Donnan GA. Endovascular thrombectomy and stroke physicians: equity, access, and standards.Stroke. 2017; 48:2042–2044. doi: 10.1161/STROKEAHA.117.018208.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Regenhardt R, Rosenthal J, Awad A, Martinez-Gutierrez J, Nolan N, McIntyre J, Whitney C, Alotaibi N, Dmytriw A, Vranic J, Stapleton C, Patel A, Rost N, Schwamm L and Leslie-Mazwi T (2021) 'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2021-017819, 14:7, (650-653), Online publication date: 1-Jul-2022. Glober N, Faris G, Montelauro N, Tainter C, Myers S, Arkins T, Vaizer J, Latta C and Lardaro T (2022) Factors Affecting Interfacility Transport Intervals in Stroke Patients Transferred for Endovascular Therapy, Prehospital Emergency Care, 10.1080/10903127.2022.2082608, (1-6) Glober N, Supples M, Persaud S, Kim D, Liao M, Glidden M, O'Donnell D, Tainter C, Boustani M, Alexander A and Doyle K (2022) A novel emergency medical services protocol to improve treatment time for large vessel occlusion strokes, PLOS ONE, 10.1371/journal.pone.0264539, 17:2, (e0264539) Tong X, Wang Y, Fiehler J, Bauer C, Jia B, Zhang X, Huo X, Luo G, Wang A, Pan Y, Ma N, Gao F, Mo D, Song L, Sun X, Liu L, Deng Y, Li X, Wang B, Ma G, Wang Y, Ren Z, Miao Z, Miao Z, Gui L, Song C, Peng Y, Wu J, Zhao S, Zhao J, Zhou Z, Li Y, Jing P, Yang L, Liu Y, Zhao Q, Liu Y, Peng X, Gao Q, Guo Z, Chen W, Li W, Cheng X, Xu Y, Zhang Y, Zhang G, Lu Y, Lu X, Wang D, Wang Y, Li H, Hua Y, Geng D, Yuan H, Wang H, Yang H, Wang Z, Wei L, Liufu X, Shi X, Li J, Yang W, Jing W, Yong X, Wang L, Li C, Cao Y, Zhu Q, Zhang P, Luo X, Chen S, Peng W, Wang L, Wen X, Shi S, Wang W, Bo W, Yuan P, Wang D, Guan H, Liang W, Ma D, Chen L, Xiao Y, Xie X, Shi Z, Zeng X, Su F, Chang M, Yin J, Sun H, Li C, Bi Y, Xie G, Zhao Y, Wang C, Zhang P, Wang X, Li D, Liang H, Chen Z, Wang Y, Xin Y, Yin L, Qiu H, Wei J, Sun Y, Feng X, Wu W, Gao L, Ai Z, Lan T, Ding L, Liang Q, Wang Z, Yang J, Xu P, Dong W, Zheng Q, Zhu Z, Zhao L, Meng Q, Wei Y, Chen X, Wang W, Sun D, Yan Y, Yuan G, Yang Y, Zhou J, Yang Z, Zhang Z, Guan N and Wang H (2021) Thrombectomy Versus Combined Thrombolysis and Thrombectomy in Patients With Acute Stroke, Stroke, 52:5, (1589-1600), Online publication date: 1-May-2021.Schlemm L, Endres M and Nolte C (2021) Cost Effectiveness of Interhospital Transfer for Mechanical Thrombectomy of Acute Large Vessel Occlusion Stroke, Circulation: Cardiovascular Quality and Outcomes, 14:4, Online publication date: 1-Apr-2021.Stein L, Tuhrim S, Jette N, Fifi J, Mocco J and Dhamoon M (2020) Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke, Stroke, 51:12, (3651-3657), Online publication date: 1-Dec-2020. Pallesen L, Winzer S, Barlinn K, Prakapenia A, Siepmann T, Gruener C, Gerber J, Haedrich K, Linn J, Barlinn J and Puetz V (2020) Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy, Scientific Reports, 10.1038/s41598-020-62528-4, 10:1, Online publication date: 1-Dec-2020. Feil K, Rémi J, Küpper C, Herzberg M, Dorn F, Kunz W, Rotkopf L, Heinrich J, Müller K, Laub C, Levin J, Hüttemann K, Dabitz R, Müller R, Wollenweber F, Pfefferkorn T, Hamann G, Liebig T, Dieterich M and Kellert L (2019) Drip and ship for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria, Neurology, 10.1212/WNL.0000000000008753, 94:5, (e453-e463), Online publication date: 4-Feb-2020. Stein L, Tuhrim S, Fifi J, Mocco J and Dhamoon M (2019) Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke, Stroke, 50:7, (1789-1796), Online publication date: 1-Jul-2019. Venema A, Uyttenboogaart M and Absalom A (2019) Land of confusion: anaesthetic management during thrombectomy for acute ischaemic stroke, British Journal of Anaesthesia, 10.1016/j.bja.2018.12.004, 122:3, (300-304), Online publication date: 1-Mar-2019. Chartrain A, Shoirah H, Jauch E and Mocco J (2018) A review of acute ischemic stroke triage protocol evidence: a context for discussion, Journal of NeuroInterventional Surgery, 10.1136/neurintsurg-2018-013951, 10:11, (1047-1052), Online publication date: 1-Nov-2018. Di Maria F, Mazighi M, Kyheng M, Labreuche J, Rodesch G, Consoli A, Coskun O, Gory B and Lapergue B (2018) Intravenous Thrombolysis Prior to Mechanical Thrombectomy in Acute Ischemic Stroke: Silver Bullet or Useless Bystander?, Journal of Stroke, 10.5853/jos.2018.01543, 20:3, (385-393), Online publication date: 30-Sep-2018. December 12, 2017Vol 136, Issue 24 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.031444PMID: 29229619 Originally publishedDecember 12, 2017 Keywordsthrombolytic therapystrokeEditorialsthrombectomyPDF download Advertisement
Referência(s)