Large Vessel Occlusion: Primary or Comprehensive Stroke Center With Endovascular Capabilities?

Mar 07, 2016   |  Prashant Vaishnava, MD, FACC
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Authors:
Southerland AM, Johnston KC, Molina CA, Selim MH, Kamal N, Goyal M.
Citation:
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):

  1. 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.
  2. That said, intravenous tissue-type plasminogen activator (IV-tPA) remains a highly efficacious and proven treatment for AIS.
  3. 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.
  4. 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.
  5. Endovascular treatment is safe and highly effective (number needed to treat of 2.5-7 in recent trials).
  6. Direct transfer to CSC bypassing primary stroke centers (PSCs) for EVT represents a novel clinical equipoise for which a randomized clinical trial is needed.
  7. Direct transfer to CSC should not be at the expense of delays in administration of IV-tPA.
  8. 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.
  9. 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.
  10. 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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