Higher Mortality and Reduced Independence in ICH Patients Transferred to Endovascular Center

Core Concepts

Direct transfer to an endovascular center for ICH patients leads to higher mortality and reduced functional independence.

Abstract

In a secondary analysis of the RACECAT trial, patients with intracranial hemorrhage (ICH) who were directly transferred to an endovascular treatment (EVT)-capable stroke center had lower chances of functional independence at 3 months. This transfer was also associated with higher mortality and increased risk of medical complications, including in-hospital pneumonia. The study highlights the importance of prehospital transport protocols for stroke patients and the impact on outcomes based on the destination center.

Key Highlights:

• Direct transfer to an endovascular center led to worse functional outcomes and higher mortality.
• Patients transferred to endovascular centers had a higher risk of medical complications and pneumonia.
• The study emphasizes the need to reevaluate prehospital transport protocols for stroke patients.

Stats

Direct transfer to an endovascular center resulted in worse functional outcomes at 90 days (adjusted odds ratio, 0.63; 95% CI, 0.41 - 0.96).
Medical complications during initial transfer were higher for patients transferred to endovascular centers (aOR: 5.29; 95% CI, 2.38 - 11.73).
In-hospital pneumonia rates were significantly higher for patients transferred to endovascular centers (OR: 2.61; 95% CI, 1.53 - 4.44).

Quotes

"To the best of our knowledge, the present study provides the first data from a randomized clinical trial about the effect of different prehospital transport protocols among patients experiencing ICH." - Anna Ramos-Pachón, MD

Key Insights Distilled From

Higher Mortality With Transfer to Endovascular Center in ICH

by Batya Swift ... at www.medscape.com 08-28-2023

https://www.medscape.com/viewarticle/995921

Deeper Inquiries

How can prehospital triage protocols be improved to better differentiate between ICH and LVO ischemic stroke?

The differentiation between intracranial hemorrhage (ICH) and large vessel occlusion (LVO) ischemic stroke is crucial for determining the appropriate treatment pathway and optimizing outcomes for patients. To enhance prehospital triage protocols in this regard, several strategies can be implemented. Firstly, there is a need for the development and validation of more accurate prehospital stroke severity scales that can reliably distinguish between ICH and LVO ischemic stroke. These scales should incorporate specific clinical and radiological markers that are indicative of each condition. Additionally, the integration of advanced imaging technologies, such as mobile CT scanners or point-of-care ultrasound, in the prehospital setting can aid in rapid and accurate diagnosis. Training emergency medical services (EMS) personnel in the recognition of key clinical features and symptoms that differentiate ICH from LVO ischemic stroke is also essential. By improving the accuracy of prehospital triage algorithms through these measures, timely and appropriate care can be provided to patients, leading to better outcomes.

What are the implications of these findings for stroke care protocols in urban settings?

The findings from the study have significant implications for stroke care protocols, particularly in urban settings where access to specialized stroke centers may be more readily available. In urban areas with multiple stroke centers, the decision-making process regarding the destination for patients with suspected stroke becomes crucial. The study's results suggest that a generalized bypass transfer protocol, where patients are directly transferred to an endovascular treatment (EVT)-capable stroke center, may not always be beneficial, especially for patients ultimately diagnosed with ICH. In urban settings, where the proximity of stroke centers may be closer compared to nonurban areas, the emphasis should be on optimizing the accuracy of prehospital triage to ensure that patients are routed to the most appropriate facility based on their specific condition. This may involve a more nuanced approach to patient transport, taking into account individual patient characteristics, stroke severity, and the availability of specialized services at different centers. By tailoring stroke care protocols to the unique characteristics of urban settings, healthcare providers can improve patient outcomes and resource utilization.

How can early point-of-care biomarkers improve outcomes for ICH patients in the prehospital setting?

Early point-of-care biomarkers have the potential to revolutionize the management of patients with intracranial hemorrhage (ICH) in the prehospital setting by enabling rapid and accurate diagnosis, risk stratification, and treatment decisions. These biomarkers can provide valuable information about the underlying pathophysiology of ICH, such as the type of hemorrhage, its volume, and the presence of associated complications. By detecting specific biomarkers indicative of ICH, such as markers of inflammation, coagulation, or neuronal injury, healthcare providers can promptly initiate targeted interventions and optimize patient care. Additionally, point-of-care biomarkers can aid in the early identification of patients at high risk of complications, such as pneumonia or neurological deterioration, allowing for timely preventive measures. Integrating early point-of-care biomarkers into prehospital triage protocols can streamline the diagnostic process, facilitate appropriate resource allocation, and ultimately improve outcomes for ICH patients by enabling personalized and timely interventions.