Endovascular Thrombectomy for Acute Ischemic Strokes

 But you blithering idiots still don't know how fast you have to deliver tPA or endovascular thrombectomy to get 100% recovery. 

Time is brain is NOT GOOD ENOUGH!

Endovascular Thrombectomy for Acute Ischemic Strokes

 

Amrou Sarraj

,

Sean Savitz

,

Deep Pujara

,

Haris Kamal

,

Kirsten Carroll

,

Faris Shaker

,

Sujan Reddy

,

Kaushik Parsha

,

Lauren E. Fournier

,

Erica M. Jones

,

Anjail Sharrief

,

Sheryl Martin-Schild

,

James Grotta

Originally published12 Feb 2020https://doi.org/10.1161/STROKEAHA.120.028850Stroke. 2020;51:1207–1217

Abstract

Background and Purpose—

Timely access to endovascular thrombectomy (EVT) centers is vital for best acute ischemic stroke outcomes.(Best is not good enough, 100% recovery is the only goal in stroke. When the fuck will you get there?)

Methods—

US stroke-treating centers were mapped utilizing geo-mapping and stratified into non-EVT or EVT if they reported ≥1 acute ischemic stroke thrombectomy code in 2017 to Center for Medicare and Medicaid Services. Direct EVT-access, defined as the population with the closest facility being an EVT-center, was calculated from validated trauma-models adapted for stroke. Current 15- and 30-minute access were described nationwide and at state-level with emphasis on 4 states (TX, NY, CA, IL). Two optimization models were utilized. Model-A used a greedy algorithm to capture the largest population with direct access when flipping 10% and 20% non-EVT to EVT-centers to maximize access. Model-B used bypassing methodology to directly transport patients to the nearest EVT centers if the drive-time difference from the geo-centroid to hospital was within 15 minutes from the geo-centroid to the closest non-EVT center.

Results—

Of 1941 stroke-centers, 713 (37%) were EVT. Approximately 61 million (19.8%) Americans have direct EVT access within 15 minutes while 95 million (30.9%) within 30 minutes. There were 65 (43%) EVT centers in TX with 22% of the population currently within 15-minute access. Flipping 10% hospitals with top population density improved access to 30.8%, while bypassing resulted in 45.5% having direct access to EVT centers. Similar results were found in NY (current, 20.9%; flipping, 34.7%; bypassing, 50.4%), CA (current, 25.5%; flipping, 37.3%; bypassing, 53.9%), and IL (current, 15.3%; flipping, 21.9%; bypassing, 34.6%). Nationwide, the current direct access within 15 minutes of 19.8% increased by 7.5% by flipping the top 10% non-EVT to EVT-capable in all states. Bypassing non-EVT centers by 15 minutes resulted in a 16.7% gain in coverage.

Conclusions—

EVT-access within 15 minutes is limited to less than one-fifth of the US population. Optimization methodologies that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT-access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT-access.

Introduction

Endovascular thrombectomy (EVT) improves clinical outcomes, reduces disability, and saves lives for patients with acute ischemic strokes (AISs) due to anterior circulation large vessel occlusion (LVO). Several randomized clinical trials^1–5 have proven thrombectomy efficacy and safety up to 6 hours from last known well (LKW) as compared with medical management only. Recently, the DAWN trial (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo)⁶ and DEFUSE 3 trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)⁷ extended thrombectomy efficacy and safety up to 24 hours from LKW in selected patients.

Even with EVT efficacy up to 24 hours from LKW, time remains an important factor that affects EVT outcome.⁸ Thus, timely and direct access to EVT capable centers remains vital to improving clinical outcomes of patients with AIS due to LVO. Current stroke care algorithms largely prioritize initial transport of patients with stroke to the closest hospital equipped with the ability to administer IV tPA (intravenous tissue-type plasminogen activator). Therefore, the majority of patients only have access to EVT through inter-hospital transfers (drip and ship model), which are associated with significant treatment delays and worsen outcomes.⁹ Strategies to improve current direct access are necessary to achieve optimal clinical outcomes in patients with strokes. Furthermore, there are no clear data on the current distribution or density of EVT-capable centers in the United States, their coverage areas, and, subsequently, the gaps in patient access to timely thrombectomy.

We evaluated current EVT-capable center distribution and identified the current US population with direct EVT access within 15 and 30 minutes utilizing geomapping techniques. Moreover, we attempted to optimize current direct EVT access in all states, with a focused assessment of 4 states, by deploying 2 optimization methodologies to maximize the endovascular coverage for the states’ population.