Study Evaluates Primary Stroke Center Protocol for Suspected Stroke by Emergent Large Vessel Occlusion
July 12, 2017—An investigation of whether a three-point standardized protocol would improve efficiency and outcomes in the treatment of patients suspected of having an emergent large vessel occlusion (ELVO) who present to a primary stroke center (PSC) was published by Ryan A. McTaggart, MD, et al in Journal of the American Medical Association (JAMA): Neurology (2017;74:793–800). The protocol is based on (1) early notification to the closest comprehensive stroke center (CSC), (2) CTA imaging at the PSC, and (3) electronic image sharing before transfer.
This retrospective cohort study demonstrated that when the PSC protocol was fully executed, the rate of good outcomes doubled and the time from arrival at the PSC to reperfusion at the CSC was almost 1 hour less than that with only partial execution of the protocol. The investigators advised that this protocol can be easily replicated between PSC and CSC partners and may improve stroke care delivery for patients with ELVOs presenting to centers without endovascular capability.
As summarized in JAMA: Neurology, 14 regional PSCs unfamiliar with the management of patients with ELVOs were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score of 4 or higher: notify the CSC on arrival, perform CTA concurrently with noncontrast CT of the brain within 30 minutes of arrival, and share imaging data with the CSC using a cloud-based platform.
Between July 1, 2015 and May 31, 2016, a total of 101 patients were transferred from regional PSCs to the CSC and underwent mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km (4 and 45.7 miles) away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred during an 11-month period were reviewed, and they were divided into two groups based on whether the PSC protocol was partially or fully executed.
The primary outcomes were efficiency measures including time from PSC door-in to PSC door-out, time from PSC door to CSC groin puncture, and 90-day modified Rankin scale score (range, 0–6; scores of 0–2 indicate a good outcome).
The investigators reported that of the 101 patients transferred, 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%; mean age, 77 years [interquartile range, 65–84 years]; 22 [45%] were women). The protocol was fully executed for 22 patients (31.4%; mean age, 76 years [interquartile range, 59–86 years]; 13 [59.1%] were women).
When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture from 151 minutes (95% confidence [CI], 141–166 min) to 111 minutes (95% CI, 88–130 min; P < .001). This was primarily related to an improvement in the time from PSC door-in to door-out that reduced from a median time of 104 minutes (95% CI, 82–112 min) to a median time of 64 minutes (95% CI, 51–71 min; P < .001). When the protocol was fully executed, patients were twice as likely to have favorable outcomes (50% vs 25%; P < .04), stated the investigators in JAMA: Neurology.