Interfacility transfer for mechanical thrombectomy – Direct to neuroangiography or CT angiography first?

Published:October 15, 2019DOI:https://doi.org/10.1016/j.jns.2019.116508

      Highlights

      • Transfer direct to neuroangiography might speed time to thrombectomy in stroke.
      • However, based on CT/CTA thrombectomy was aborted in 2/3 of transferred patients.
      • In early presenters with severe stroke, a direct to angio approach may be reasonable.

      Abstract

      Background and purpose

      Faster time to mechanical thrombectomy (MT) improves outcome in stroke. In patients from other hospitals where a CT has ruled-out hemorrhage, transfer direct-to-angiography (DTA) may reduce door-to-groin time compared to transfer to CT angiography (CTA)+/−repeat CT first. However, this may result in unnecessary catheter angiography. We sought to determine how often CTA+/−CT changed the decision to proceed to MT.

      Methods

      Data on patients transferred to our comprehensive stroke center (CSC) from outside facilities for possible MT from 7/2016–5/2017 was extracted from a prospective database and supplemented with chart review.

      Results

      Of 170 patients transferred for MT undergoing CT+/−CTA on CSC arrival, MT was aborted in 108 (64%). Of these, 87 (81%) were aborted directly based on imaging findings, with absence of large vessel occlusion or occlusion too distal to be amenable to MT the most common reasons (n = 76), followed by extensive early CT changes (n = 9) and ICH post-tPA (n = 2). Even with NIHSS ≥10 on CSC arrival, MT was aborted based on imaging findings in 35% patients. Time from symptom onset dichotomized as early/late based on median onset-to-CSC arrival (253 min) was an important modifier of proceeding to MT in this group, with 71% of early presenters going to MT compared to 33% of late presenters (p = .003).

      Conclusions

      Transfer DTA may result in many patients who would have been excluded based on CT+/−CTA findings undergoing unnecessary catheter angiography. However, a target population for a DTA approach might be identifiable based on severity of deficit and time from onset.

      Keywords

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