Background and purpose We investigated whether the annual volume of patients with acute ischemic stroke referred from a primary stroke center (PSC) for endovascular treatment (EVT) is associated... Show moreBackground and purpose We investigated whether the annual volume of patients with acute ischemic stroke referred from a primary stroke center (PSC) for endovascular treatment (EVT) is associated with treatment times and functional outcome. Methods We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) registry (2014-2017). We included patients with acute ischemic stroke of the anterior circulation who were transferred from a PSC to a comprehensive stroke center (CSC) for EVT. We examined the association between EVT referral volume of PSCs and treatment times and functional outcome using multivariable regression modeling. The main outcomes were time from arrival at the PSC to groin puncture (PSC-door-to-groin time), adjusted for estimated ambulance travel times, time from arrival at the CSC to groin puncture (CSC-door-to-groin time), and modified Rankin Scale (mRS) score at 90 days after stroke. Results Of the 3637 patients in the registry, 1541 patients (42%) from 65 PSCs were included. Mean age was 71 years (SD +/- 13.3), median National Institutes of Health Stroke Scale score was 16 (interquartile range [IQR]: 12-19), and median time from stroke onset to arrival at the PSC was 53 min (IQR: 38-90). Eighty-three percent had received intravenous thrombolysis. EVT referral volume was not associated with PSC-door-to-groin time (adjusted coefficient: -0.49 min/annual referral, 95% confidence interval [CI]: -1.27 to 0.29), CSC-door-to-groin time (adjusted coefficient: -0.34 min/annual referral, 95% CI: -0.69 to 0.01) or 90-day mRS score (adjusted common odds ratio: 0.99, 95% CI: 0.96-1.01). Conclusions In patients transferred from a PSC for EVT, higher PSC volumes do not seem to translate into better workflow metrics or patient outcome. Show less
Background and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to... Show moreBackground and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT. Methods We used data from the MR CLEAN Registry (2014-2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders. Results Of the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p < 0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted beta = - 51.6, 95% CI: - 64.0 to - 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted beta = - 44.0, 95% CI: - 65.5 to - 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73-2.08). Conclusions In patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome. Show less
