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Original research
Impact of landmark endovascular stroke trials on logistical performance measures: a before-and-after evaluation of real-world data from a regional stroke system of care
  1. Alexander Marco Kollikowski1,
  2. Franco Amaya1,
  3. Guido Stoll2,
  4. Wolfgang Müllges2,
  5. Michael Klaus Schuhmann2,
  6. Mirko Pham1
  1. 1 Department of Neuroradiology, University Hospital of Würzburg, Würzburg, Germany
  2. 2 Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
  1. Correspondence to Dr Alexander Marco Kollikowski, Department of Neuroradiology, University Hospital of Würzburg, Würzburg 97080, Germany; kollikowsk_a{at}


Background and purpose Endovascular treatment of large-vessel occlusion stroke often necessitates patient transfer by a twin-track approach: endovascular thrombectomy (ET) in endovascular-capable facilities preceded by intravenous thrombolysis in primary stroke centers. We tested the open hypothesis that recent landmark trials on ET had any significant effect on logistical performance measures among different modes of admission.

Methods We retrospectively categorized 250 patients who presented at our institution as: (A) primarily admitted or transferred from (B) inner-city and (C) regional hospitals. The period from May 2015 to June 2017 was compared with the preceding period of August 2009 to April 2015 with respect to real-life transfer distances and sectional time metrics from symptom onset to angiographic recanalization.

Results Onset-to-recanalization time decreased in the primary admission path, whereas delays persisted for inter-hospital transfer: (A: 261 min (210–315) vs 198 (167–264) P<0.0001; B: 257 (214–306) vs 265 (199– 360) P=0.566; and C: 371 (322–415) vs 346 (307–405) P=0.559). Onset-to-recanalization time was negatively correlated with recanalization success (mTICI; r=-0.4195 P<0.0001). The rate of secondarily referred patients (26% vs 48% P=0.0004) and off-hour presentation (36% vs 44% P=0.004) increased, as did the catchment area (C: 52.2 km (30,4–64,5) vs 64.4 (43,2–78,9) P=0.032). Improvement in door-in-door-out time at the referring hospitals (C: 113 min (30) vs 86 (29) P=0.0236) did not translate into reduced total referral times or the accelerated initiation of ET.

Conclusion Recent landmark trials already led to a considerable streamlining of ET workflow if patients were directly admitted. Prehospital time management and triage seem to be the major determinants of optimization.

  • intervention
  • stroke
  • thrombectomy

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  • Contributors AMK and MP conceptualized the study. AMK performed data acquisition, analysis, and interpretation. AMK and MP co-wrote and edited the first draft of the manuscript. FA, GS, WM, and MKS provided support at all stages and critically reviewed and/or revised the manuscript for significant intellectual content. All authors have contributed to production of the final version of this manuscript.

  • Funding AK/MP/GS were supported by a research grant from the Deutsche Forschungsgemeinschaft (DFG CRC/TR B02).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethics Committee of the University Hospital of Würzburg.

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