Large Vessel Occlusion: Primary or Comprehensive Stroke Center With Endovascular Capabilities?
- Southerland AM, Johnston KC, Molina CA, Selim MH, Kamal N, Goyal M.
- Suspected Large Vessel Occlusion: Should Emergency Medical Services Transport to the Nearest Primary Stroke Center or Bypass to a Comprehensive Stroke Center With Endovascular Capabilities. Stroke 2016;Feb 19:[Epub ahead of print].
The following are 10 key points to remember from a commentary on management of acute ischemic stroke (AIS):
- Endovascular therapy (EVT) in AIS may represent a paradigm shift in treatment, as select patients with anterior circulation stroke and proximal large vessel occlusion (LVO) have favorable outcomes with timely reperfusion using stent retriever thrombectomy.
- That said, intravenous tissue-type plasminogen activator (IV-tPA) remains a highly efficacious and proven treatment for AIS.
- Every 15-minute acceleration in start of IV-tPA results in a 4% increased likelihood of independence. Delays in IV-tPA and diversion adding >15 to 20 minutes to transport should be avoided.
- EVT is only offered in comprehensive stroke centers (CSCs), which makes access to this highly beneficial therapy difficult for patients who are outside the catchment area of a CSC.
- Endovascular treatment is safe and highly effective (number needed to treat of 2.5-7 in recent trials).
- Direct transfer to CSC bypassing primary stroke centers (PSCs) for EVT represents a novel clinical equipoise for which a randomized clinical trial is needed.
- Direct transfer to CSC should not be at the expense of delays in administration of IV-tPA.
- Conversely, initial transfer to a PSC for the purposes of tPA early before going to a CSC for EVT could result in delays in endovascular treatment.
- Most AIS patients presenting via emergency medical services will not have a retrievable LVO and are ineligible for EVT, questioning the value of a strategy that bypasses PSCs in favor of CSCs.
- As the authors write, “We need to pick good swimmers (with LVO), to start a fast and long swim course directly to the CSC shore, from the crowd of regular swimmers (without LVO), who just need a short swim to the nearest stroke center beach.”
Keywords: Emergency Medical Services, Endovascular Procedures, Graft Occlusion, Vascular, Reperfusion, Secondary Prevention, Stents, Stroke, Thrombectomy, Tissue Plasminogen Activator, Vascular Diseases
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