Do cur­rent logistics ensure better odds and outcome in acute large ves­sel occlusion patients?


Authors: D. Krajíčková 1;  A. Krajina 2;  E. Vítková 1;  S. Halúsková 1;  O. Vyšata 1;  R. Herzig 1
Authors‘ workplace: Neurologická klinika, Komplexní cerebrovaskulární centrum LF UK a FN Hradec Králové 1;  Radiologická klinika, Komplexní cerebrovaskulární centrum LF UK a FN Hradec Králové 2
Published in: Cesk Slov Neurol N 2018; 81(3): 338-344
Category: Original Paper
doi: 10.14735/amcsnn2018338

Tato studie byla částečně podpořena grantovými projekty MZ ČR (FN HK 00179906) a Univerzity Karlovy (PROGRES Q40).

Overview

Aim:
The chance of a good result of mechanical thrombectomy (MT) for a large cerebral artery occlusion is directly proportional to the speed of its execution. The aim was to find differences in outcome in patients transported primarily and secondarily to the Comprehensive Stroke Center (CSC) of the University Hospital Hradec Králové.

Patients and Methods:
Out of 258 consecutive patients, 171 were transported to the CSC for MT primarily and 87 secondarily, from the primary stroke center. Clinical data, including intervals from the onset of cerebral ischemia and arrival to the center and then to treatment, were compared with clinical trials and the STRATIS registry and in both groups. The indicator of treatment effectiveness was the achievement of successful recanalization (TICI ≥ 2b) and self-sufficiency in 3 months (mRS ≤ 2).

Results:
Despite the fact that in secondarily transported patients MT was started and completed significantly later (271.7 ± 96.8 min vs. 175.7 ± 63.9 min, and 321.3 ± 107.6 min vs. 226.4 ± 72.3 min, resp.; both p < 0.0001), these patients had a statistically insignificant tendency towards a higher proportion of self-sufficiency (63.2 vs. 46.8%) and lower mortality (14.9 vs. 21.1%). They were statistically significantly younger (68.8 ± 13.2 vs. 73.4 ± 12.8 years; p = 0.007), with a lower proportion of patients > 80 years (17.0 vs. 33.3%; p = 0.043) and a higher proportion of tandem pathologies (24.1 vs. 11.7%; p = 0.036).

Conclusion:
Our results suggest that selection associated with secondary transport excludes a group of more risky patients from endovascular treatment.

Key words:
ischemic stroke – anterior circulation – mechanical thrombectomy – secondary transport – fast progressors – slow progressors – recanalization – clinical outcome

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


Sources

1. Berkhem­mer OA, Fransen PS, Beumer D et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Eng J Med 2015; 372(1): 11–20. doi: 10.1056/ NEJMoa1411587.

2. Goyal M, Demchuk AM, Menon BK et al. Randomized as­ses­sment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372(11): 1019– 1030. doi: 10.1056/ NEJMoa1414905.

3. Campbell BC, Mitchell PJ, Kleinig TJ et al. Endovascular ther­apy for ischemic stroke with perfusion-imag­­ing selection. N Engl J Med 2015; 372(11): 1009– 1018. doi: 10.1056/ NEJMoa1414792.

4. Saver JL, Goyal M, Bonafe A et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372(24): 2285– 2295. doi: 10.1056/ NEJMoa1415061.

5. Jovin TG, Chamor­ro A, Cobo E et al. Thrombectomy within 8 hours after symp­tom onset in ischemic stroke. N Eng J Med 2015; 372(24): 2296– 2306. doi: 10.1056/ NEJMoa1503780.

6. Powers WJ, Derdeyn CP, Bil­ler J et al. 2015 American Heart As­sociation/ American Stroke As­sociation focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regard­­ing endovascular treatment: a guideline for healthcare profes­sionals from the American Heart As­sociation/ American Stroke As­sociation. Stroke 2015; 46(10): 3020– 3035. doi: 10.1161/ STR.0000000000000074.

7. Wahlgren N, Moreira T, Michel P et al. Mechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska Stoke Update 2014/ 2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 2016; 11(1): 134– 147. doi: 10.1177/ 1747493015609778.

8. Adams HP Jr, del Zoppo G, Alberts MJ et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart As­sociation/ American Stroke As­sociation Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Pe­ripheral Vascular Dis­ease and Quality of Care Outcomes in Research Interdisciplinary Work­­ing Groups: The American Academy of Neurology af­firms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38(5): 1655– 1711. doi: 10.1161/ STROKEAHA.107.181486.

9. Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare profes­sionals from the American Heart As­sociation/ American Stroke As­sociation. Stroke 2013; 44(3): 870– 947. doi: 10.1161/ STR. 0b013e318284056a.

10. Šaňák D, Neumann J, Tomek A et al. Doporučení pro rekanalizační léčbu akutního mozkového infarktu –  verze 2016. Cesk Slov Neurol N 2016; 79/ 112(2): 231– 234. doi: 10.14735/ amcsn­n2016231.

11. Škoda O, Herzig R, Mikulík R et al. Klinický standard pro dia­gnostiku a léčbu pa­cientů s ischemickou cévní mozkovou příhodou a s tranzitorní ischemickou atakou –  verze 2016. Cesk Slov Neurol N 2016; 79/ 112(3): 351– 363. doi: 10.14735/ amcsn­n2016351.

12. Bel­lwald S, Weber R, Dobrocky T et al. Direct mechanical intervention versus bridg­­ing ther­apy in stroke patients eligible for intravenous thrombolysis: a pooled analysis of 2 registries. Stroke 2017; 48(12): 3282– 3288. doi: 10.1161/ STROKEAHA.117.018459.

13. Fisher U, Kaesmacher J, Pereira VM et al. Direct mechanical thrombectomy versus combined intravenous and mechanical thrombectomy in large-artery anterior circulation stroke. A topical review. Stroke 2017; 48(10): 2912– 2918. doi: 10.1161/ STROKEAHA.117.017208.

14. Bar M. Pa­cient s hemiplegií má být vezen přímo do KCC. Cesk Slov Neurol N 2017; 80/ 113(4): 392– 393.

15. Šrámek M. Pa­cient s hemiplegií nemá být vezen přímo do KCC. Cesk Slov Neurol N 2017; 80/ 113(4): 394.

16. Školoudík D. Má být pa­cient s hemiplegií vezen přímo do KCC? Cesk Slov Neurol N 2017; 80/ 113(4): 395.

17. Goldstein LB, Samsa GP. Reliability of the National Institute of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke 1997; 28(2): 307– 310.

18. Wahlgren N, Ahmed N, Dávalos A et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitor­­ing Study (SITS-MOST): an observational study. Lancet 2007; 369(9558): 275– 282. doi: 10.1016/ S0140-6736(07)60149-4.

19. Yoo AJ, Simonsen CZ, Prabhakaran S et al. Cerebral Angiographic Revascularization Grad­­ing Col­laborators. Refin­­ing angiographic bio­markers of revascularization. Improv­­ing outcome prediction after intra-arterial ther­apy. Stroke 2013; 44(9): 2509– 2512. doi: 10.1161/ STROKEAHA.113.001990.

20. van Swieten JC, Koudstaal PJ, Vis­ser MC. Interobserver agreement for the as­ses­sment of handicap in stroke patients. Stroke 1988; 19(5): 604– 607.

21. Muel­ler-Kronast NH, Zaidat OO, Froehler MT et al. Systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke. Primary results of the STRATIS registry. Stroke 2017; 48(10): 2760– 2768. doi: 10.1161/ STROKEAHA.117.016456.

22. Saver JL, Goyal M, van der Lught A et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016; 316(12): 1279– 1288. doi: 10.100/ jama.2016.13647.

23. Roubec M, Krajíčková D, Hom­merová J et al. Predictors of good clinical outcome in patients with acute stroke undergo­­ing endovascular treatment –  results from CERBERUS. Cesk Slov Neurol N 2017; 80/ 113(6): 666– 674. doi: 10.14735/ amcsn­n2017666.

24. Goyal M, Menon BK, van Zwam WH et al. Endovascular thrombectomy after large-ves­sel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387(10029): 1723– 1731. doi: 10.1016/ S0140-6736(16)00163-X.

25. Sanos­sian N, Apibunyopas KC, Liebeskind DS et al. Characteristics and outcomes of very elderly enrol­led in a prehospital stroke research study. Stroke 2016; 47(11): 2737– 2741. doi: 10.1161/ STROKEAHA.116.013318.

26. Gastonguay AC, Zaidat OO, Novakovic R et al. Influence of age on clinical and revascularization outcomes in the North American Solitaire Stent-Retriever Acute Stroke Registry. Stroke 2014; 45(12): 3631– 3636. doi: 10.1161/ STROKEAHA.114.006487.

27. Gory B, Piotin M, Haus­sen DC et al. Thrombectomy in acute stroke with tandem occlusions from dis­section versus atherosclerotic cause. Stroke 2017; 48(11): 3145– 3148. doi: 10.1161/ STROKEAHA.117.018264.

28. Rebel­lo LC, Bouslama M, Haus­sen DC et al. Stroke etiology and col­laterals: atheroembolic strokes have greater col­lateral recruitment than embolic strokes. Eur J Neurol 2017; 24(6): 762– 767. doi: 10.1111/ ene.13287.

29. Šaňák D. Před trombektomií je třeba vždy provést IVT. Cesk Slov Neurol N 2016; 79/ 112(2): 148.

30. Herzig R. Před trombektomií není třeba vždy provést IVT. Cesk Slov Neurol N 2016; 79/ 112(2): 149.

31. Voško M. Trombektómia „s“, alebo „bez“ systémovej trombolýzy. Cesk Slov Neurol N 2016; 79/ 112(2): 150.

32. Fiehler J. The time-reset ef­fect. Thrombectomy trials chal­lenge the existence of a time window. Clin Neuroradiol 2017; 27(1): 3– 5. doi: 10.1007/ s00062-017-0561-4.

33. Pham M, Bendszus M. Fac­­ing time in ischemic stroke: an alternative hypothesis for col­lateral failure. Clin Neuroradiol 2016; 26(2): 141– 151. doi: 10.1007/ s00062-016-0507-2.

34. Rocha M, Jovin TG. Fast versus slow progres­sors of infarct growth in large ves­sel occlusion stroke. Clinical and research implications. Stroke 2017; 48(9): 2621– 2627. doi: 10.1161/ STROKEAHA.117.017673.

35. Ribo M, Molina CA, Cobo E et al. As­sociation between time to reperfusion and outcome is primarily driven by the time from imag­­ing to reperfusion. Stroke 2016; 47(4): 999– 1004. doi: 10.1161/ STROKEAHA.115.011721.

36. Milne MSW, Holodinsky JK, Hill MD et al. Drip and ship versus mother ship for endovascular treatment. Model­­ing the best transportation options for optimal outcomes. Stroke 2017; 48(3): 791– 794. doi: 10.1161/ STROKEAHA,116.015321.

Labels
Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 3

2018 Issue 3

Most read in this issue

This topic is also in:


Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account