SNIS Publishes Commentary Affirming Benefits of Direct Transport to CSCs for ELVO Patients

December 19, 2023—The Society of NeuroInterventional Surgery (SNIS) announced the publication of an Editor’s Column by David Fiorella, MD, et al in the Journal of NeuroInterventional Surgery (JNIS), in which leaders of the society conclude that the entire body of research, including evidence from two new prospective trials, clearly confirm that most patients with emergent large vessel occlusions (ELVOs) benefit from triage directly to comprehensive stroke centers (CSCs).

According to SNIS, the JNIS editorial urged hospital stakeholders to consider that data from two recent seemingly negative trials (TRIAGE-STROKE and RACECAT) actually provide confirmatory evidence that a direct triage program—where patients with ELVO are transported directly to CSCs—is beneficial for patients in most geographies in the United States and worldwide. In Europe, CSCs are called thrombectomy capable enters (TCCs). Such direct triage programs are endorsed by officials of the National Association of State Emergency Medical Services (EMS), noted SNIS.

The SNIS leaders noted that since the release of the prospective data earlier this year, trade media and select hospital systems have issued messaging proclaiming, without qualification, that direct triage programs are ineffective. They advised that this has caused concerns about risks to patient care and outcomes in the neurointerventional community.

“Misinterpreting both studies—which were stopped early—poses a grave risk to our patients in the United States and much of the international community,” commented Dr. Fiorella in the SNIS press release. “We’ve begun to see the effects, with some primary stroke centers (PSCs) and hospital systems leveraging perceived financial incentives to interrupt lifesaving, direct-to-CSC triage policies.” Dr. Fiorella, a senior member of SNIS, is Director of the Stony Brook Cerebrovascular Center in Stony Brook, New York.

The authors of RACECAT noted that the study included a very large, diffusely populated, nonurban geography in Catalonia, Spain, where all TCCs are clustered in Barcelona—a system structure that is vastly different than much of the United States. The majority (56%) of patients triaged directly to a TCC required > 60 minutes of transport time, having little relevance to most of the United States population who live within ≤ 1 hour of a CSC. Moreover, the EMS providers in Catalonia were not able to “administer treatment,” unlike United States–based EMS, which further exacerbated the detrimental effects of prolonged transport times to farther facilities.

The editorial stated that TRIAGE-STROKE reported data overwhelmingly in favor of direct triage to a CSC for ELVOs, but it failed to reach statistical significance given its small study population. The data on intravenous lytic administration also supported previous studies demonstrating that excess transportation time required to get to a CSC does not diminish access to lytic therapy. Additionally, the study found evidence that the risk of dependence or death was higher for stroke patients triaged to a PSC first, rather than directly to a CSC, whether they had an ELVO or not.

As noted in the SNIS press release, mechanical thrombectomy is not only considered effective for eligible patients but is firmly established globally as the standard of care for ELVO patients. However, the efficacy of such stroke therapies is largely dependent on time to treatment, and not all stroke centers are equipped to treat these patients, further emphasizing the need for quick and appropriate protocols.

“Much of the neurointerventional field is alarmed that these studies are being aggressively and inappropriately applied to interrupt or prevent direct transport programs from being implemented,” commented SNIS President Mahesh Jayaraman, MD, in the society’s press release. “We must continue to apply triage and transport models that are proven to save lives. These are life-and-death decisions, and it is our duty as care providers to prioritize patient outcomes over additional profits.”