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• W2913784223 abstract "Almost a quarter of a century has passed since the National Institute of Neurological Disorders and Stroke (NINDS) t-PA trial began to transform the emergency treatment of acute ischemic stroke (AIS), based on a rigid 3-hour window from the patient's last known well (LKW) time.1 Twenty years later, the mechanical thrombectomy era was ushered in by compelling outcome data from trials of large-vessel occlusion (LVO) AIS patients selected for mechanical thrombectomy within 4.5 hours from LKW, based on CT perfusion (CTP) and magnetic resonance imaging mismatch criteria.2, 3 More recently, it was reported that similar mismatch criteria can identify patients who can benefit from endovascular reperfusion therapy as far out as 24 hours from LKW.4 Indeed, advanced imaging selection criteria threaten to make any acute time-based window for treatment obsolete, including that for systemic thrombolysis.5-7 This evolution of AIS treatment, and the challenges it poses for developing regionalized systems of acute stroke care, are discussed in a review published in this month's issue of Academic Emergency Medicine.8 While the imperative to create such regionalized acute stroke care systems has never been more apparent,9, 10 whether or not we succeed with stroke, as we have with ST-elevation myocardial infarction (STEMI),11 remains to be seen. It has been often stated that the Holy Grail of regionalized acute stroke care is finding the “STEMI 12-lead ECG equivalent for stroke,” which would not only identify AIS in the field, but also accurately distinguish LVO AIS from non-LVO AIS. This effort has yielded an acronym soup of derived LVO screens (LAMS, RACE, C-STAT, VAN, FANG-D, LEGS, PASS, FAST-ED) that, as Miller et al suggest, all lack rigorous study of reproducibility and validity.12, 13 However, this lack of evidence has not hindered several states from enacting statewide policies mandating the use of a prehospital LVO screen to inform “routing protocols.”14, 15 That the term “routing” has replaced “bypass” as the preferred vernacular for referring to such protocols is not coincidental. It undeniably reflects the threat that such protocols can pose in regions where several stroke centers of varying capabilities compete as the preferred destination for EMS patients. Market competition aside, more concerning may be the impact of undertriage and overtriage that such policies may create. Since the 15% overtriage rate deemed acceptable for suspected STEMI routing to a percutaneous coronary intervention center is unlikely to be achieved for stroke,13 it appears likely that regions adopting these policies may need to tolerate overtriage rates closer to the 50% rate judged acceptable for major trauma patients. This is largely due to the low prevalence of LVO stroke in the EMS population screened,16 which, when coupled with nonspecific screens, becomes a recipe for overtriage. This concern was pointed out in a recently conducted systematic review commissioned by the American Heart Association/American Stroke Association,13 which was intended to support the recommendations of their updated stroke guidelines originally published in January 2018. Interestingly, a “corrected” version of these guidelines emerged 4 months later, which notably seemed to ignore the findings of their commissioned study.17 How and why this correction came about remains unclear, but it disregards the recognition that work remains until severity-based stroke routing can be widely endorsed. Such work should include simulation modeling, which has the potential to quantify the likely impact of specific routing schemes before implementation, so that protocols can be tailored for the local characteristics of specific regions. For example, such modeling found that Mecklenburg County North Carolina could nearly double the number of LVO patients routed to a thrombectomy capable center by adjusting the permissible increased EMS transport time from 10 to 20 minutes but would only marginally benefit from increasing the allowable time beyond 20 minutes. However, simulations in King County Washington suggested that increasing from 20 to 30 minutes of permitted additional transport time corresponded to a 28% increase of patients with LVO directly transported to an ESC.18 Furthermore, it must be acknowledged that routing may not be best for all LVO patients, as recent data demonstrate IV t-PA recanalizes 30% of all LVOs and is more likely to be successful with more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment.19 Such patients, it would seem, would benefit more from timely systemic thrombolysis, than from treatment delays associated with direct routing to a thrombectomy center. Importantly, a prospective, multicenter, cluster randomized trial comparing the strategy of transferring suspected acute LVO AIS patients to the closest local stroke center versus direct transfer to an endovascular stroke center is ongoing (RACECAT, NCT0279596225).20 This study, which is targeted to be completed in 2020, is likely to provide important insight into the hazard of misclassification of non-LVO patients and the possibility of early recanalization after thrombolysis. Coupled with the aforementioned challenges of field to facility triage are the challenges and work needed to improve interfacility triage and transport of LVO AIS patients who will inevitably initially present to nonendovascular centers, regardless of how successful routing becomes. This is perhaps best reflected in recent data reporting that 54% to 73% of interfacility transfers for intended mechanical thrombectomy did not go on to receive endovascular intervention on arrival at the thrombectomy center.21, 22 Even more concerning is that 44% to 48% of these false-positive thrombectomy transfers were transported by helicopter. This demonstrates the need for better methods of triage and patient selection to identify those likely to benefit from emergent transfer for endovascular intervention. At a minimum, CT angiography (CTA) should be required to confirm the presence of a target LVO. Additionally, it is becoming increasingly apparent that CTP capability is highly beneficial for nonthrombectomy centers to select patients with a favorable tissue mismatch, as was done in all of the CT-based extended window trials and two of the early window trials demonstrating the efficacy of mechanical thrombectomy.2-4, 23 Utilization of advanced imaging at nonthrombectomy centers is further supported by quantitative estimates demonstrating that its deployment would result in significantly fewer futile transfers for endovascular therapy.24 Additionally, emerging data suggest that CTP may help predict which transferred patients may proceed rapidly to the angiography suite, without repeat imaging on arrival to the endovascular center, based on parameters such as a low hypoperfusion index and high relative cerebral blood volume in the hypoperfused region, which are strong indicators of good collateral circulation and slow infarct growth.25, 26 Nonetheless, even with prompt identification of LVO patients, it is recognized that delay in hospital-to-hospital transfer is a common reason that many patients are excluded from interventional therapy.27 To prevent such delays, it is essential that thrombectomy centers work closely with their referral hospitals to develop protocols leveraging the early identification of thrombectomy eligible LVO patients now possible though advanced imaging. Even with CTA alone, it has been shown that a strategy consisting of timely CTA performance at nonthrombectomy sites, early communication to the referral thrombectomy center, and efficient electronic image sharing between hospitals can improve efficiency and outcomes.28 While the treatment options for LVO AIS patients have never been more promising, responsibly applying recent advancements over an increasingly expanding time window since patients were LKW represents a challenge. Especially considering that over the next 40 years, the number of incident strokes is expected to more than double (with the majority of the increase likely to occur among those aged ≥ 75 years),29 it will be essential that regional systems of acute stroke care are thoughtfully designed. Stakeholders in these regional systems must resist premature implementation of policies and protocols that have been insufficiently studied and have the potential to overwhelm current emergency care resources. Instead, we need to all work together to study, create, and then deliver the next generation of regionalized acute stroke care." @default.
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• W2913784223 date "2019-03-03" @default.
• W2913784223 modified "2023-09-27" @default.
• W2913784223 title "Implementation Challenges of Regionalized Acute Stroke Care" @default.
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• W2913784223 doi "https://doi.org/10.1111/acem.13696" @default.
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