West Virginia University School of Medicine, Morgantown, West Virginia.
West Virginia University, Department of Pathology, Morgantown, West Virginia.
West J Emerg Med. 2023 Jun 30;24(4):737-742. doi: 10.5811/westjem.59770.
Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients.
We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes.
In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001).
Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.
尽管急性脑卒中血管内治疗（EVT）显著改善了大血管闭塞（LVO）急性缺血性脑卒中（AIS）患者的预后，但获得 EVT 能力中心的机会仍然有限，尤其是在农村地区。因此，优化 EVT 合格患者的分诊系统至关重要。一种策略可能是使用远程脑卒中网络，该网络通常由多个辐条站点组成，这些辐条站点接收咨询，以确定将患者转移到 EVT 能力中心的适宜性。为了实现在 EVT 合格患者到达中心时目标门到腹股沟（DTG）时间小于 60 分钟，可能需要标准化 AIS 方案。具体来说，在辐条站点获得血管成像与延迟到中心获得血管成像的决策存在争议。本研究的目的是确定与 LVO-AIS 患者 DTG 时间缩短相关的因素。
我们对我们的本地中心机构在 3.5 年期间治疗的所有患者进行了回顾性图表审查。患者被分为远程脑卒中转移、非远程脑卒中转移和直接到中心就诊。我们记录了人口统计学信息、DTG 时间、再灌注状态、住院时间（LOS）、出院时的功能状态、七天死亡率以及获得血管成像-计算机断层血管造影（CTA）的位置。我们进行了二元逻辑回归分析，以确定与 DTG<60 分钟相关的因素。
在可接受 EVT 的患者样本（n=383）中，53%的患者在转移到中心机构之前在辐条站点进行了 CTA。此外，与非远程脑卒中转移相比，59%的远程脑卒中转移病例在转移前接受了 CTA（59%比 40%，P=0.01）。在接受了预先转移 CTA 的转移患者中，67%的患者实现了 DTG<60 分钟，而在接受了中心转移 CTA 的转移患者中，这一比例仅为 22%，在直接到中心就诊的患者中，这一比例为 17%。最终，与未接受 CTA 的患者相比，在转移前接受 CTA 的转移患者 DTG<60 分钟的可能性高 7.2 倍（OR 7.2，95%置信区间 3.5-14.7；P<0.001）。
预先转移的计算机断层血管造影是唯一能显著预测是否能达到 60 分钟内目标门到腹股沟时间的因素。由于 DTG 时间已被证明是临床预后的预测因素，包括在标准化急性缺血性脑卒中方案中进行预先转移的 CTA，可能会证明是有益的。我们的研究结果还表明，需要优化直接到中心的脑卒中警报和远程脑卒中关系，以尽量减少工作流程中断，这在大流行期间变得更加明显。
