From the Baptist Neurological Institute, Lyerly Neurosurgery, Baptist Health, Jacksonville, FL (A.A., R.H., E.S., M.F.G.).
Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, Hermitage, PA (A.P.J.).
Stroke. 2019 Aug;50(8):2163-2167. doi: 10.1161/STROKEAHA.119.025710. Epub 2019 Jul 15.
Background and Purpose- The impact of transfer status on clinical outcomes in the DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) population is unknown. We analyzed workflow and clinical outcome differences between direct versus transfer patients in the DAWN population. Methods- The following time metrics were analyzed for each group: (1) last known well to hospital arrival, (2) hospital arrival to eligibility imaging, (3) hospital arrival to arterial puncture, (4) qualifying imaging to arterial puncture, (5) last known well to arterial puncture, (6) last known well to reperfusion. The primary end point was the rate of functional independence (90-day modified Rankin Scale [mRS] score, 0-2). Using univariate unconditional logistic regression, we calculated odds ratios and 95% CIs for the association between clinically relevant time metrics, transfer status, and functional independence (mRS 0-2). Results- A total of 206 patients were enrolled. Among these, 121 (59%) patients were transferred, and 85 (41%) patients presented directly to a thrombectomy capable center. Median time last seen well to hospital arrival time was similar between the 2 groups (678 versus 696 minutes). The time from hospital arrival to groin puncture was significantly longer in direct patients compared with transferred patients 140 minutes (interquartile range, 105.5-177.5 minutes) and 88 minutes (interquartile range, 55-125 minutes), respectively (P<0.001). Differences in treatment effect or differences in rates of mRS 0-2 in the thrombectomy treated patients were not statistically significant in direct versus transfer patients (odds ratios for mRS 0-2, thrombectomy versus control, were 5.62 in direct and 6.63 in transfer patients, respectively, Breslow-Day P=0.817). Conclusions- Although transfer patients had a faster door to puncture time, benefits of thrombectomy, and rates of mRS 0 to 2 in the treatment group were similar between direct and transferred patients in the DAWN population. These results may inform prehospital and primary stroke centers triage protocols in patients presenting in the late time window. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02142283.
转移状态对 DAWN（通过 DWI 或 CTP 评估进行的治疗选择，在醒后和晚期发病的接受神经介入治疗的卒中患者中，采用临床不匹配进行的治疗选择）人群的临床结局的影响尚不清楚。我们分析了 DAWN 人群中转诊患者与直接就诊患者之间的工作流程和临床结局差异。方法：分析了两组患者的以下时间指标：（1）从最后一次已知正常到入院时间，（2）从入院到符合条件的影像学检查时间，（3）从入院到动脉穿刺时间，（4）从符合条件的影像学检查到动脉穿刺时间，（5）从最后一次已知正常到动脉穿刺时间，（6）从最后一次已知正常到再灌注时间。主要终点是功能独立性率（90 天改良 Rankin 量表[mRS]评分，0-2 分）。使用单变量非条件逻辑回归，我们计算了临床相关时间指标、转移状态和功能独立性（mRS 0-2 分）之间的关联的优势比和 95%置信区间。结果：共纳入 206 例患者。其中，121 例（59%）患者为转诊患者，85 例（41%）患者直接到有取栓能力的中心就诊。两组患者从最后一次已知正常到入院的中位时间相似（678 分钟比 696 分钟）。与转诊患者相比，直接就诊患者从入院到股动脉穿刺的时间明显延长，分别为 140 分钟（四分位间距 105.5-177.5 分钟）和 88 分钟（四分位间距 55-125 分钟）（P<0.001）。直接就诊患者和转诊患者的治疗效果或 mRS 0-2 率无统计学差异（mRS 0-2 分的优势比，取栓治疗与对照组，分别为直接就诊患者 5.62 和转诊患者 6.63，Breslow-Day P=0.817）。结论：尽管转诊患者的门到穿刺时间更快，但在 DAWN 人群中，直接就诊患者和转诊患者的取栓治疗获益和 mRS 0-2 率相似。这些结果可能为在晚期时间窗就诊的患者的院前和初级卒中中心分诊方案提供信息。临床试验注册：网址：https://www.clinicaltrials.gov。唯一标识符：NCT02142283。
