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September 11, 2019

Study Supports Field Triage of Endovascular Stroke Therapy Candidates to Comprehensive Stroke Centers

September 9, 2019—Principal Investigators Mahesh V. Jayaraman MD, and Ryan A. McTaggart MD, led a population-based study of emergency medical services–determined field triage for endovascular stroke therapy (EVT) that compared times to treatment and outcomes between patients taken to the closest primary stroke center (PSC) with those triaged in the field to a more distant comprehensive stroke center (CSC). The findings are available online in Journal of NeuroInterventional Surgery (JNIS). Dr. Jayaraman and Dr. McTaggart are Associate Professors of Diagnostic Imaging, Neurology, and Neurosurgery at Warren Alpert School of Medicine at Brown University in Providence, Rhode Island.

As summarized in JNIS, a portion of the investigators’ region allowed field triage of patients who met severity criteria to a more distant CSC than the closest PSC. The remaining patients were transported to the closest PSC. In addition to comparing times to treatment and clinical outcomes between those two groups, the investigators performed a matched-pairs analysis of patients from both groups on stroke severity and distance to CSC. Over 2 years, 232 patients met inclusion criteria and were closest from the field to a PSC. Of these patients, 144 were taken to the closest PSC and 88 to the more distant CSC.

The investigators reported in JNIS:

  • The median additional transport time to the CSC was only 7 minutes.
  • Times from scene departure to alteplase and arterial puncture were faster in the direct group (50 vs 62 min; 93 vs 152 min; P < .001 for both).
  • Among patients who were independent before the stroke, the odds ratio for less disability in the direct group was 1.47 (95% CI, 1.13–1.93; P = .003) and 2.06 (95% CI, 1.10–3.89; P = .01) for the matched pairs.

In JNIS, the investigators concluded that in a densely populated setting, for patients with stroke who are EVT candidates and closest to a PSC from the field, triage to a slightly more distant CSC is associated with faster time to EVT, no delay to alteplase, and less disability at 90 days.

Dr. Jayaraman and Dr. McTaggart discussed the study’s implications with Endovascular Today. They commented, “These results have significant implications for development of stroke systems of care. Protocols for field triage should incorporate a stroke severity score and take patients to the most appropriate center, which in some cases may not be the closest one.”

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