Froehler Michael T, Saver Jeffrey L, Zaidat Osama O, Jahan Reza, Aziz-Sultan Mohammad Ali, Klucznik Richard P, Haussen Diogo C, Hellinger Frank R, Yavagal Dileep R, Yao Tom L, Liebeskind David S, Jadhav Ashutosh P, Gupta Rishi, Hassan Ameer E, Martin Coleman O, Bozorgchami Hormozd, Kaushal Ritesh, Nogueira Raul G, Gandhi Ravi H, Peterson Eric C, Dashti Shervin R, Given Curtis A, Mehta Brijesh P, Deshmukh Vivek, Starkman Sidney, Linfante Italo, McPherson Scott H, Kvamme Peter, Grobelny Thomas J, Hussain Muhammad S, Thacker Ike, Vora Nirav, Chen Peng Roc, Monteith Stephen J, Ecker Robert D, Schirmer Clemens M, Sauvageau Eric, Abou-Chebl Alex, Derdeyn Colin P, Maidan Lucian, Badruddin Aamir, Siddiqui Adnan H, Dumont Travis M, Alhajeri Abdulnasser, Taqi M Asif, Asi Khaled, Carpenter Jeffrey, Boulos Alan, Jindal Gaurav, Puri Ajit S, Chitale Rohan, Deshaies Eric M, Robinson David H, Kallmes David F, Baxter Blaise W, Jumaa Mouhammad A, Sunenshine Peter, Majjhoo Aniel, English Joey D, Suzuki Shuichi, Fessler Richard D, Delgado Almandoz Josser E, Martin Jerry C, Mueller-Kronast Nils H
Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.).
University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.).
Circulation. 2017 Dec 12;136(24):2311-2321. doi: 10.1161/CIRCULATIONAHA.117.028920. Epub 2017 Sep 24.
Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.
STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0-2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.
A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06-1.79; =0.02). Likewise, excellent outcome (modified Rankin Score 0-1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13-1.92; =0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; =0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.
In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.
尽管治疗效果高度依赖时间，但血管内机械取栓术（MT）对急性缺血性卒中且伴有大血管闭塞的患者有益。我们推测，与直接就诊相比，转院至具备血管内治疗能力的中心会导致治疗延迟并产生更差的临床结局。
STRATIS（急性缺血性卒中神经取栓装置治疗患者的系统评估）是一项前瞻性、多中心、观察性、单臂研究，针对2年内55个地点因前循环大血管闭塞导致的急性卒中进行的真实世界MT治疗，纳入1000例重症卒中患者且在8小时内接受治疗。患者接受了MT治疗，部分联合静脉注射组织纤溶酶原激活剂，并通过院间转运或直接就诊的方式入住具备血管内治疗能力的中心。主要临床结局为90天时的功能独立性（改良Rankin量表评分0 - 2分）。我们评估了（1）卒中治疗实施的真实世界时间指标，（2）接受MT治疗的直接就诊患者与转院患者的结局差异，以及（3）当地医院绕行的潜在影响。
共分析了984例患者。直接就诊患者从发病到血管再通的中位时间为202.0分钟，而转院患者为311.5分钟（<0.001）。直接就诊组的临床结局更好，直接就诊组60.0%（299/498）实现功能独立，而转院组为52.2%（213/408）（优势比，1.38；95%置信区间，1.06 - 1.79；P = 0.02）。同样，直接就诊患者中47.4%（236/498）获得了良好结局（改良Rankin量表评分0 - 1分），而转院患者为38.0%（155/408）（优势比，1.47；95%置信区间，1.13 - 1.92；P = 0.005）。两组死亡率无差异（直接就诊组为15.1%，转院组为13.7%；P = 0.55）。静脉注射组织纤溶酶原激活剂不影响结局。对所有转院患者的假设性绕行模型分析表明，如果患者直接被送往具备血管内治疗能力的中心，静脉注射组织纤溶酶原激活剂将延迟12分钟，但MT将提前91分钟进行。如果绕行仅限于发病半径20英里范围内，那么静脉注射组织纤溶酶原激活剂将延迟7分钟，MT提前94分钟进行。
在这项大型真实世界研究中，院间转运与显著的治疗延迟和良好结局机会较低相关。促进更快速识别大血管闭塞并将重症卒中患者直接送往具备血管内治疗能力中心的策略可能会改善结局。
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