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  • 'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model

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Ischemic stroke
Original research
'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model
  1. Robert W Regenhardt1,2,
  2. Joseph A Rosenthal2,
  3. Amine Awad2,
  4. Juan Carlos Martinez-Gutierrez2,
  5. Neal M Nolan2,
  6. Joyce A McIntyre2,
  7. Cynthia Whitney2,
  8. Naif M Alotaibi1,
  9. Adam A Dmytriw1,3,4,
  10. Justin E Vranic1,4,
  11. Christopher J Stapleton1,
  12. Aman B Patel1,
  13. Natalia S Rost2,
  14. Lee H Schwamm2,
  15. Thabele M Leslie-Mazwi1,2
  1. 1 Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Neuroradiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  4. 4 Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Robert W Regenhardt, Neurosurgery and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; robert.regenhardt{at}mgh.harvard.edu

Abstract

Background Randomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., ‘drip-and-ship’ model) versus those not.

Methods Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b–3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence.

Results Among 258 patients, median age was 70 years (IQR 60–81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b–3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06).

Conclusions Intravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.

  • large vessel occlusion thrombectomy
  • acute ischemic stroke
  • intravenous thrombolysis
  • drip-and-ship
  • endovascular thrombectomy

Data availability statement

The data that support the findings of this study will be made available from the corresponding author uponon reasonable request and pending approval of the local institutional review board.

https://doi.org/10.1136/neurintsurg-2021-017819

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    Data availability statement

    The data that support the findings of this study will be made available from the corresponding author uponon reasonable request and pending approval of the local institutional review board.

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    Footnotes

    • RWR and JAR are joint first authors.

    • Twitter @rwregen

    • RWR and JAR contributed equally.

    • Contributors All authors have made significant contributions to this work. All have read and approved the final version of this manuscript.

    • Funding The National Institutes of Health, National Institute of Neurological Disorders and Stroke, supported this work (RWR by R25 NS065743).

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction, or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.