Background Randomized trials have recently shown that intra-arterial (IA) treatment of large vessel occlusion (LVO) acute ischemic stroke (AIS) with new generation devices is highly effective at restoring perfusion and significantly improving outcome. As these trials were performed at high-volume academic centers, it remains unclear whether these results can be replicated in the community setting outside of a clinical trial, or in a "drip and ship" referral model. Since May 2012, the California Pacific Medical Center (CPMC) in San Francisco has treated referral acute LVO AIS patients using CT, CT angiography and CT perfusion (CTP) combined with stent-retriever based IA therapy.
Methods IA AIS cases performed at CPMC between May 2012 and October 2014 were reviewed. CTP scans were evaluated by the stroke neurologist and neurointerventionist to determine suitability for intervention (e.g., core infarct volume, perfusion mismatch). Automated software was not utilized. Baseline demographics including age, NIHSS, IV tPA treatment, and time points pertinent to CTP imaging and procedural times were collected. The primary safety endpoint was symptomatic ICH (sICH), and the primary outcome was mRS at 90 days; secondary endpoints included successful reperfusion and mortality.
Results 108 patients were treated, 20 with Solitaire and 88 with Trevo. The majority of patients (88%) were transferred via the CPMC Northern California Telestroke Network. The median age was 66.1 and the median NIHSS was 15.2. 72% of patients were treated with IV tPA, most prior to transfer. Median onset of symptoms to imaging at CPMC was 296 min. All procedures were performed under general anesthesia. Median CT scan to groin puncture was 136 min. Median CT scan to reperfusion was 205 min. TICI 2B or 3 reperfusion was achieved in 77%, with a median of 2.3 passes. 90 day outcome data was available in 102 patients, with 62% achieving a favorable outcome (mRS of 0–2). sICH was noted in 5.5% of patients. 90 day mortality was 14%.
Conclusions Endovascular treatment of LVO AIS based upon selection with CT perfusion imaging and modern stent retriever technology can be feasible, safe, and effective in the community setting. Times from imaging to groin puncture and reperfusion were longer compared to recent trials, however mRS at 90 days and sICH ratees were comparable. Good outcomes were noted despite long stroke onset to CTP times for many patients, emphasizing the potential role of CTP imaging in identifying patients with favorable perfusion and small core infarct who can benefit from IA therapy at extended time periods. These data suggest that a ‘drip and ship’ approach with a hub/spoke model commonly utilized by comprehensive stroke centers and in Telemedicine networks may provide benefit to this patient population, and can be achieved in a community setting.
Disclosures B. Gao: None. N. Barazangi: None. D. Tong: None. C. Chen: None. C. Wong: None. A. Yee: None. M. Morrow: None. A. Bedenk: None. W. Kim: 2; C; Stryker Neurovascular, Silk Road Medical. J. English: 1; C; Stryker Neurovascular. 2; C; Stryker Neurovascular, Covidien, Silk Road Medical.