Department of Neurology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, United States.
Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, United States.
Clin Neurol Neurosurg. 2021 Jan;200:106371. doi: 10.1016/j.clineuro.2020.106371. Epub 2020 Nov 13.
The Dawn and Extend Intra-Arterial (IA) acute stroke intervention trials have proven the benefit of thrombectomy in a select group of patients up to 24 h since their last known well time (LKWT) or time of symptom onset. Following the issuance of new treatment guidelines for large vessel occlusion strokes, we reviewed the paradigm shift effect on transfers for possible thrombectomy in a rural state.
Extended time window for thrombectomy increases the need for better identification of potential transfers for thrombectomy in rural states with few hospitals capable of 24/7 interventional thrombectomy.
We analyzed all transfers to a comprehensive stroke center (CSC) from January to December 2018 which were specifically transferred for possible further intervention. This time period was selected in accordance with the change in American Heart Association (AHA) guidelines for extended time windows in mechanical thrombectomy (MT) care.
A total of 132 patients were transferred for possible thrombectomy and advanced imaging. Thirty-four % patients underwent diagnostic angiogram with 33% patients having successful MT. Of the excluded patients 19% had large core infarcts by the time they arrived at hub hospital, 1.5% had hemorrhagic conversion, 32% had stroke without treatable occlusion not amenable for thrombectomy or cortical strokes on follow-up imaging, and 13.5% did not have stroke or LVO on follow-up imaging.
Since the AHA's change in time window guidelines for mechanical thrombectomies, there has been an increased effort in identifying good candidates with computerized tomography angiography (CTA). To avoid undue burden on stroke systems of care, CTA identification of these patients at the spoke hospitals is key along with timely transport to appropriate thrombectomy capable sites. Given the rural nature of this state along with limited resources, selection of patients is a practical issue, especially for avoiding futile transfers, which might be true for large areas of the USA.
黎明和扩展动脉内（IA）急性卒中干预试验已经证明了在最后一次已知的良好时间（LKWT）或症状发作时间后 24 小时内，对选择的患者进行血栓切除术的益处。在新的大血管闭塞性卒中治疗指南发布后，我们回顾了这一范式转变对农村州可能进行血栓切除术的转院的影响。
血栓切除术的延长时间窗口增加了在仅有少数医院能够 24/7 进行介入性血栓切除术的农村州，更好地识别潜在转院患者的需求。
我们分析了 2018 年 1 月至 12 月期间所有转运至综合卒中中心（CSC）的患者，这些患者是专门为进一步干预而转运的。选择这段时间是为了符合美国心脏协会（AHA）关于机械血栓切除术（MT）治疗延长时间窗口的指南的变化。
共有 132 名患者为可能的血栓切除术和高级成像而转院。34%的患者进行了诊断性血管造影，其中 33%的患者进行了成功的 MT。在排除的患者中，19%的患者在到达中心医院时已经有大核心梗死，1.5%的患者发生了出血性转化，32%的患者在随访成像上有非治疗性闭塞或皮质卒中，或无卒中或 LVO，13.5%的患者在随访成像上没有卒中或 LVO。
自从 AHA 改变了机械血栓切除术的时间窗口指南以来，人们更加努力地通过计算机断层血管造影（CTA）来识别合适的患者。为了避免给卒中护理系统带来不必要的负担，在卫星医院通过 CTA 识别这些患者并及时转运至适当的血栓切除术能力的地点是关键。考虑到该州的农村性质和有限的资源，患者的选择是一个实际问题，尤其是为了避免无益的转院，这可能在美国的大部分地区都是如此。
