Kuc Alexander, Overberger Ryan, Isenberg Derek L, Henry Kevin A, Zhao Huquing, Sigal Adam, Wojcik Susan, Herres Joseph, Brandler Ethan, Nomura Jason T, Kraus Chadd K, Ackerman Daniel, Peluso Arianna, Gentile Nina
Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey.
Department of Emergency Medicine, Jefferson Einstein Hospital, Philadelphia, Pennsylvania.
Prehosp Emerg Care. 2024 Aug 19:1-6. doi: 10.1080/10903127.2024.2388882.
Large vessel occlusion (LVO) strokes may be eligible for treatment with intravenous thrombolysis (IVT) and endovascular therapy (EVT). Patients selected for treatment have better neurologic outcomes with EVT, and delays in this therapy lead to worse outcomes. However, EVT is offered at a limited number of hospitals, referred to as endovascular stroke centers (ESC). This poses a difficult decision for EMS: to take potential stroke patients to the closest primary stroke center (PSC) or longer transport time to a more distant ESC. We hypothesized that patients with LVO stroke undergoing EVT transported directly to an ESC would have more favorable outcomes as measured by the modified Rankin scale (mRS) at 90 days, compared to transport to a PSC followed by transfer to an ESC.
The OPUS-REACH consortium examined transportation patterns and outcomes in patients with LVO stroke who received endovascular treatment. This cohort includes 2400 patients with LVO stroke throughout eight endovascular centers in the Northeast U.S. from 2015 to 2020. All patients enrolled in the OPUS-REACH database were eligible for inclusion. Patients were excluded if they were missing the pickup address, had an in-hospital stroke, or arrived mobile stroke unit. The remaining patients were separated into two groups: the bypass group, with transportation by EMS to an ESC by bypassing PSC, and the non-bypass group, with initial transport to PSC and interfacility transport to an ESC. The primary outcome was the modified Rankin scale (mRS) at 90 days, where 0-2 was defined as "good".
The primary outcome did not reach significance with 40% of the bypass group as compared with the 33.1% of the non-bypass group having a "good" outcome. However, the bypass group underwent shorter times from last-known-well to both thrombolysis (120.9 vs 153.3 min, < 0.001) and thrombectomy (356.1 vs 454.8 min, = 0.001).
In patients with LVO stroke who undergo thrombectomy, EMS transport directly to an ESC results in shorter time thrombectomy, although we did not observe a difference in 90-day functional outcomes. Additionally, bypass to reach a more capable endovascular stroke center does not delay administration of IVT from time of LKW.
大血管闭塞（LVO）性卒中患者可能适合接受静脉溶栓（IVT）和血管内治疗（EVT）。选择接受治疗的患者接受EVT后神经功能结局更好，而延迟这种治疗会导致更差的结局。然而，只有少数医院提供EVT，即血管内卒中中心（ESC）。这给急救医疗服务（EMS）带来了一个艰难的决定：是将潜在的卒中患者送往最近的初级卒中中心（PSC），还是花费更长的转运时间送往更远的ESC。我们假设，与先送往PSC然后转至ESC相比，直接送往ESC接受EVT治疗的LVO性卒中患者在90天时根据改良Rankin量表（mRS）测量的结局会更有利。
OPUS-REACH联盟研究了接受血管内治疗的LVO性卒中患者的转运模式和结局。该队列包括2015年至2020年美国东北部8个血管内中心的2400例LVO性卒中患者。所有纳入OPUS-REACH数据库的患者均符合纳入标准。如果患者缺少接送地址、发生院内卒中或乘坐移动卒中单元到达，则被排除。其余患者分为两组：旁路组，由EMS绕过PSC直接送往ESC；非旁路组，先送往PSC，然后在医疗机构间转运至ESC。主要结局是90天时的改良Rankin量表（mRS），其中0 - 2被定义为“良好”。
主要结局未达到显著性，旁路组40%的患者结局“良好”，而非旁路组为33.1%。然而，旁路组从最后已知正常状态到溶栓的时间（120.9分钟对153.3分钟，<0.001）和取栓时间（356.1分钟对454.8分钟，=0.001）均较短。
在接受取栓治疗的LVO性卒中患者中，EMS直接送往ESC可缩短取栓时间，尽管我们未观察到90天功能结局的差异。此外，绕过初级卒中中心前往更有能力的血管内卒中中心不会延迟从最后已知正常状态开始的IVT给药。
