Conference Coverage

Conference News Update—Society of Neurointerventional Surgery


 

References

Emergency Transport Times
 for Patients With Stroke
 Need Improvement

Despite efforts to close the time gap between symptom onset and stroke treatment—including improvements in public education, 911 dispatch operations, prehospital detection and triage, hospital stroke system development, and stroke unit management—a study suggests that delays in emergency transport are still prevalent and that improvements are needed to ensure that patients can be treated within the optimal time window.

Perhaps more than any other condition, stroke requires timely diagnosis and treatment to yield the best possible outcomes for patients. Three recent stroke studies—MR CLEAN, ESCAPE, and EXTEND IA—demonstrated that the success of endovascular therapy resulted in part from reducing the time it took for patients to access treatment. Evaluation of Transfer Times for Emergent Stroke Patients from Regional Centers to a Comprehensive Stroke Center, a study conducted at Vanderbilt University Medical Center in Nashville, specifically focused on time intervals associated with hospital-to-hospital transfer because most patients in the United States are transported to a regional center that is not equipped to treat all levels of stroke. Recording 70 patient transfer times within a one-year timeframe, the study found that all transfer times were significantly longer than expected driving times, and average differences per hospital ranged from 46 to 133 minutes.

“Stroke requires a multidisciplinary team that engages in a nuanced chain of events leading to treatment, and efficient and prompt patient transport via Emergency Medical Services (EMS) is a significant link in the process,” said Michael Froehler, MD, PhD, lead study author and neurointerventionalist at the Cerebrovascular Program at Vanderbilt University Medical Center. “Within the broader stroke community, we’ve definitely made progress in our systems of care that ensure [that] an increasing number of patients receive treatment as quickly as possible. But we need to do more.”

The conversation on time to treatment is not without precedent. Within the past decade, the American Heart Association/American Stroke Association has put forth guidelines designed to advocate that stroke patients receive the highest level of care in the shortest time possible. Many state legislatures have created stroke prevention task forces and developed statewide stroke prevention plans. Individual counties and cities have established systems to ensure that EMS personnel are equipped to appropriately assess patients and immediately transfer them to the closest certified stroke center. Despite these efforts, transfer times often remain beyond the preferred treatment time window.

“The challenge to improve upon stroke systems of care is an opportunity to transform the way we approach stroke treatment, and we’re seeing the most progress in the cities, states, and regions that are engaging in collective efforts to ensure that patients go to the hospital that is best equipped to treat stroke,” said Donald Frei, MD, president of the Society of Neurointerventional Surgery. “We have a unique responsibility to continue to invest our time, resources, and best thinking to better assist our patients and to continually refine systems of care that will facilitate optimal stroke treatment.”

Dr. Froehler pointed out that most changes in systems of care, while well-intentioned, are often not informed by evidence from trials. He has therefore initiated a controlled study of stroke care systems at Vanderbilt University Medical Center by comparing different approaches to transporting patients with stroke to the right hospital faster. “It’s important that we continue to inform best practices and evolve our systems for the good of patients who depend on rapid response and timely intervention. We must rigorously apply the same evidence-based standards that we use for individual patient treatment decisions to the broader systems of care in order to achieve necessary efficiencies that can make a real difference for our patients,” said Dr. Froehler.

Device Innovation Improves 
Outcomes of Stroke Treatment

In the last decade, intra-arterial stroke therapy has gained notable momentum as an effective and safe treatment option for patients. Two studies further reinforce the value and progress of intra-
arterial treatment. The authors conclude that the innovative new devices that facilitate this approach are reducing treatment times, improving outcomes, and decreasing mortality rates.

Since stent retrievers became available in 2012, no comparative analysis with older devices had been conducted to determine differences in utilization or clinical outcomes. In the Trends and Outcomes of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke: A Review of National In-Patient Database, joint investigators Srikanth Boddu, MD, an interventional neuroradiologist at New York Presbyterian Hospital, and Ning Lin, MD, a neurosurgeon at Weill Cornell Medical Center in New York, used the Nationwide Inpatient Sample (NIS) database provided by the Agency for Healthcare Research and Quality (AHRQ) to analyze outcomes associated with three generations of devices, including devices that emerged in 2006 and 2007 (ie, Post-MERCI), 2008 and 2011 (ie, Post-Penumbra), and 2012 (stent
retrievers).

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