Regenhardt Robert W, Awad Amine, Kraft Andrew W, Rosenthal Joseph A, Dmytriw Adam A, Vranic Justin E, Bonkhoff Anna K, Bretzner Martin, Etherton Mark R, Hirsch Joshua A, Rabinov James D, Singhal Aneesh B, Rost Natalia S, Stapleton Christopher J, Leslie-Mazwi Thabele M, Patel Aman B
Neurosurgery, Massachusetts General Hospital.
Neurology, Massachusetts General Hospital.
Stroke Vasc Interv Neurol. 2022 Sep;2(5). doi: 10.1161/svin.121.000282. Epub 2022 May 20.
Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility.
Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2.
Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time.
Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.
血管内血栓切除术（EVT）的可及性相对有限。轴心辐射式网络旨在将合适的大血管闭塞（LVO）患者转运至具备EVT能力的中心。然而，部分患者在抵达中心时不符合条件，且导致转运效率低下的因素尚未得到充分描述。我们试图量化EVT转运效率，并确定EVT不符合条件的原因。
从一个前瞻性维护的数据库中，识别出2018年至2020年期间连续就诊于25个分支、具有转运前CTA定义的LVO且ASPECTS≥6的EVT候选患者。感兴趣的结局包括中心EVT、EVT不符合条件的原因以及90天改良Rankin量表（mRS）评分≤2。
在258例患者中，年龄中位数为70岁（四分位间距60 - 81岁）；50%为女性。56%的患者在抵达中心后不符合EVT条件。所述原因包括大面积陈旧性梗死（49%）、症状轻微（33%）、再通（6%）、远端闭塞（5%）、亚闭塞性病变（3%）以及医疗目标（3%）。晚期窗患者[最后已知正常时间（LKW）>6小时]更有可能不符合条件（67%对43%，P<0.0001）。不符合EVT条件的患者年龄更大（73岁对68岁，p = 0.04），美国国立卫生研究院卒中量表（NIHSS）评分更低（10分对16分，p<0.0001），LKW至抵达中心的时间更长（8.4小时对4.6小时，p<0.0001），分支远程卒中会诊至抵达中心的时间更长（2.8小时对2.2小时，p<0.0001），与符合条件的患者相比，接受静脉溶栓治疗的比例更低（32%对45%，p = 0.04）。在控制年龄、NIHSS和LKW至抵达中心的时间后，EVT不符合条件独立降低了90天mRS≤2的几率（调整后比值比=0.26，95%置信区间=0.12,0.56；p = 0.001）。
在因EVT而转运的患者中，抵达中心时不符合条件有多种原因，大多数因梗死灶扩大和症状轻微而被排除。了解导致转运效率低下的因素对于改善EVT的可及性和结局很重要。
