Impact of direct admission versus interfacility transfer on endovascular treatment outcomes for acute ischemic stroke: Systematic review and meta-analysis.

Abstract

INTRODUCTION\nMechanical thrombectomy is a proven treatment for large vessel ischemic stroke with improved functional outcomes when compared to intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals not able to deliver thrombectomy. The purpose of this meta-analysis is to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for pre-hospital protocols.\n\n\nMETHODS\nA meta-analysis was completed following systematic literature searches in PubMed, Cochrane, and Scopus databases. Outcomes of interest included: successful reperfusion; symptomatic intracranial hemorrhage (sICH); 90-day mRS 0-2; 90-day mortality; onset-to-puncture times; and door-to-puncture times.\n\n\nRESULTS\nOver 27,000 patients were represented in pooled analysis. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or sICH did not differ significantly between transferred and directly admitted patients, nor did 90-day mortality. While the proportion of patients achieving good functional outcome at 90 days with mRS 0-2 did not differ by admission type, when mRS was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (p <0.001).\n\n\nCONCLUSIONS\nThis meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.