RT Journal Article
SR Electronic
T1 'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model
JF Journal of NeuroInterventional Surgery
JO J NeuroIntervent Surg
FD BMJ Publishing Group Ltd.
SP neurintsurg-2021-017819
DO 10.1136/neurintsurg-2021-017819
A1 Robert W Regenhardt
A1 Joseph A Rosenthal
A1 Amine Awad
A1 Juan Carlos Martinez-Gutierrez
A1 Neal M Nolan
A1 Joyce A McIntyre
A1 Cynthia Whitney
A1 Naif M Alotaibi
A1 Adam A Dmytriw
A1 Justin E Vranic
A1 Christopher J Stapleton
A1 Aman B Patel
A1 Natalia S Rost
A1 Lee H Schwamm
A1 Thabele M Leslie-Mazwi
YR 2021
UL http://jnis.bmj.com/content/early/2021/07/29/neurintsurg-2021-017819.abstract
AB 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.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.