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Rapid and complete implementation of a standardized stroke protocol for primary stroke centers (PSCs) can significantly improve outcomes for patients with suspected stroke once they arrive at a comprehensive stroke center (CSC), according to study results recently reported in JAMA Neurology.1
The standard of care for emergent large vessel occlusion (ELVO) is intravenous tissue plasminogen activation followed by endovascular treatment of the anterior circulation, procedures that achieve optimal results when performed within a window of 6 hours after the first onset of symptoms.2-7 Comprehensive care centers are best equipped to provide these levels of care; however, many patients are first taken to PSCs for evaluation before transport to a CSC, resulting in delays to therapy.
A team of investigators from Rhode Island Hospital, the Warren Alpert School of Medicine at Brown University, and the Norman Prince Neuroscience Institute in Rhode Island created a PSC-specific front-end protocol for patients with ELVO designed to optimize early assessment and rapid transit to treatment from the time of PSC presentation to the completion of endovascular therapy at the CSC.
The first steps to this novel protocol are to be executed within a goal of <30 minutes of arrival at the PSC:
- Immediate assessment of ELVO in the emergency department and notification of the CSC for a Los Angeles Motor Scale score of ≥4;
- Dispatch of a critical care transport team from the CSC or the PSC before confirmation of LVO by imaging studies; and
- Performance of noncontrast computer tomography imaging with computer tomography angiography.
When images are available, they are sent via secure cloud-based image-sharing technology to the remote CSC stroke team, and the patient is directly transported to the CSC angiography suite.
The research group then evaluated the efficacy of their PSC protocol in a cohort of 70 patients with confirmed internal carotid artery or middle artery occlusions who first presented to PSCs and were brought to CSCs for recanalization. The majority (94.3%; n=66) underwent computer tomography angiography at the PSC, and the remaining 4 underwent the procedure at the CSC.
A total of 22 (31.4%) of the 70 ELVO patients received a fully executed protocol; 48 (68.6%) had only part or none of the protocol applied in their PSC treatment. The odds of a favorable outcome at 90 days favored the fully executed group by a ratio of 3 to 1 compared with the partial/no execution group (odds ratio, 2.99; 95% CI: 1.0-8.7). This was reflected by a significant reduction in mean National Institute of Health Stroke Scale score of 64% in the fully executed group compared with 46% in the partial/nonexecuted group (P <.001), as well as by a significantly lower modified Rankin scale score at 90 days of 2.3 (95% CI: 1.4-3.3) compared with 4.1 (95% CI: 3.4-4.7; P=.03), where a score of 0 to 2 was considered a favorable outcome.
The most notable change was an improvement in PSC door-in to door-out times, which have been shown to have a direct effect on outcomes.8-12 Times recorded in the current study were comparable to those reported in previous studies of patients with ELVO who presented directly to a CSC.8,13,14 The total door-to-needle time from PSC arrival to intravenous tissue plasminogen activation treatment in the CSC was reduced from 65 to 39.5 hours.
A few limitations to the study were noted, including the possibility of geographic variations outside the study region of Rhode Island, the use of alternative metrics to Los Angeles Motor Scale for screening of ELVO risk, and the lack of a randomized clinical trial design.
References
1. McTaggert RA, Yaghi S, Cutting SM, et al. Association of a primary care center stroke protocol for suspected stroke by large-vessel occlusion with efficiency of care and patient outcomes [published online May 7, 2017]. JAMA Neurol. doi: 10.1001/jamaneurol.2017.0477
2. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11-20.
3. Campbell BC, Mitchell PJ, Kleinig TJ, et al; for the EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018. doi: 10.1056/NEJMoa1414792
4. Goyal M, Demchuk AM, Menon BK, et al; for the ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030. doi: 10.1056/NEJMoa1414905
5. Jovin TG, Chamorro A, Cobo E, et al; for the REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306. doi: 10.1056/NEJMoa1503780
6. Powers WJ, Derdeyn CP, Biller J, et al; on behalf of the American Heart Association Stroke Council. 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;46:3020-3035. doi: 10.1161/STR.0000000000000074
7. Saver JL, Goyal M, Bonafe A, et al; for the SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295. doi: 10.1056/NEJMoa1415061
8. Saver JL, Goyal M, van der Lugt A, et al; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316:1279-1288. doi: 10.1001/jama.2016.13647
9. Sheth SA, Jahan R, Gralla J, et al; for the SWIFT-STAR Trialists. Time to endovascular reperfusion and degree of disability in acute stroke. Ann Neurol. 2015;78:584-593. doi: 10.1002/ana.24474
10. Fransen PS, Berkhemer OA, Lingsma HF. Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands Investigators. Time to reperfusion and treatment effect for acute ischemic stroke: a randomized clinical trial. JAMA Neurol. 2016;73:190-196. doi: 10.1001/jamaneurol.2015.3886
11. Khatri P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; for the IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009;73:1066-1072. doi: 10.1212/WNL.0b013e3181b9c847
12. Vagal AS, Khatri P, Broderick JP, Tomsick TA, Yeatts SD, Eckman MH. Time to angiographic reperfusion in acute ischemic stroke: decision analysis. Stroke. 2014;45:3625-3630. doi: 10.1161/STROKEAHA.114.007188
13. Sun CH, Nogueira RG, Glenn BA, et al. “Picture to puncture”: a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke. Circulation. 2013;127:1139-1148. doi: 10.1161/CIRCULATIONAHA.112.000506
14. Menon BK, Sajobi TT, Zhang Y, et al. Analysis of workflow and time to treatment on thrombectomy outcome in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) randomized, controlled trial. Circulation. 2016;133:2279-2286. doi: 10.1161/CIRCULATIONAHA.115.019983
