Abstract 4: Variation and Temporal Trends in the Characteristics of US Hospitals Treating Acute Ischemic Stroke Patients with IV-tPA: Findings from GWTG-Stroke

Introduction: Utilization of IV tPA is challenging for many hospitals. Using data from the national Get With The Guidelines-Stroke program, we analyzed changes over time in the characteristics of the hospitals that treated patients with tPA. Methods: We analyzed patient-level data from 2003-2011 at 1600 GWTG hospitals that joined the program at any time during the study period and admitted any acute ischemic stroke (AIS) patients arriving ≤ 2 hr of onset and eligible for tPA. Descriptive trends by time were analyzed by chi-square or Wilcoxon test for continuous data. Results: IV tPA was given within 3 hr at 1394 sites to 50,798/ 75,115 (67.6%) eligible AIS patients arriving ≤ 2 hr; 206 (14.8%) sites had a least one eligible patients but no tPA use. IV tPA treatment rates varied substantially across hospitals (median 61.2%, range 0-100%), with > 200 hospitals providing tPA < 10% of the time (Figure). Over time, more patients and a larger proportion of patients were treated at smaller (median bed size 407 vs. 372, p< 0.001), non-academic, Southern hospitals, and those with lower annualized average ischemic stroke volumes (252.4 vs. 235.2, p< 0.001) (Table). While more than half of all tPA patients were treated at Primary Stroke Centers, this proportion did not change over time. The proportion of patients treated at high volume tPA treatment sites (average > 20/year) increased over time (31.9 vs. 34.5, p< 0.007). Conclusion: Over the past decade, while primary stroke centers still account for more than half of all treatments, tPA has been increasingly delivered in smaller, non-academic hospitals. These data support the continued emphasis on stroke team building and systems of care at US hospitals.

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Abstract P251: Estimates and Temporal Trends for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic Stroke Treated With Thrombolytic Therapy

Stroke ◽

10.1161/str.52.suppl_1.p251 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Saqib Chaudhry ◽

Ibrahim Laleka ◽

Zelalem Bahiru ◽

Mohammad Rauf A Chaudhry ◽

Hussan S Gill ◽

...

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Temporal Trend ◽

Hospital Readmissions ◽

Temporal Trends ◽

Day Hospital ◽

Patient Centered ◽

Nationally Representative ◽

Iv Tpa

Background: Avoidance of readmission is linked to improved quality of care, reduction in cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with acute ischemic stroke treated with intravenous thrombolytic treatment (IV-tPA) are unavailable to date. Such estimates are necessary for benchmarking performance. Objectives: To identify US nationwide estimates and a temporal trend for 30-day hospital readmissions. Methods: We identified the cohort by year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (=>18 years) patients with a primary discharge diagnosis of acute ischemic (ICD-9-CM 433.x1 and 434.x1) who were treated with thrombolytic therapy (ICD-9-CM 9910). Readmission was defined as any admission within 30 days of index hospitalization discharge. Results: Based on study criteria, 57,676 eligible patients were included (mean [SE] age, 68.7 ± 14.4 years; 48.7% were women). Thirty-day readmission rate for acute ischemic stroke patients treated with IV-tPA was 11.17 % (95%CI, 10.92 %-11.43%). On average, there was a 4.4% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.95; 95%CI, 0.94-0.97). Age ≥ 65 years (OR 1.16 P <.0001), medical history of congestive heart failure (OR 1.11 P = 0.0056), chronic lung disease (OR 1.11 P = 0.0034) and renal failure (OR 1.35 P = <.0001) were independent predictors of readmission within 30 days. Conclusion: Nationally representative readmission metrics can be used to benchmark hospitals’ performance, and a temporal trend of 4.4 % may be used to evaluate the effectiveness of readmission reduction strategies.

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Abstract 2268: Trends In Reasons For Non-eligibility For tPA

Stroke ◽

10.1161/str.43.suppl_1.a2268 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Xin Tong ◽

Mary G George

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Advanced Age ◽

Stroke Patients ◽

Rapid Improvement ◽

Nihss Score ◽

Mild Stroke ◽

Over Time ◽

Iv Tpa

Background: Use of IV tPA has increased over time, as has the adherence to the NQF endorsed performance measure for receipt of IV tPA within 3 hours. Little is known about trends in the reasons for patient ineligibility for IV tPA. This study examines trends in reasons for not providing IV tPA over time and by race and gender among acute ischemic stroke patients in the Paul Coverdell National Acute Stroke Registry (PCNASR), a quality improvement program for acute stroke implemented by state health departments. Methods: There were 13,164 PCNASR patients enrolled from 2008- 2010 with a clinical diagnosis of acute ischemic stroke with documentation of LKW and who arrived within 2 hours of LKW. Cochran-Armitage tests were used to test for trend on accepted reasons for not providing IV tPA within 3 hours of time last known well (LKW). Chi-square tests were used to test for differences among reasons between men and women and between non-Hispanic whites and minorities. Multiple reasons for not giving tPA could be selected. Results: Among 13,164 acute ischemic patients admitted between 2008 and 2010 with documentation of LKW and who arrived within 2 hours of LKW, 3781 (28.7%) received IV tPA, 7284 (55.3%) had documented reasons for not receiving IV tPA, and 2099 (16.0%) did not receive IV tPA. Contraindications to IV tPA, advanced age, rapid improvement and inability to determine eligibility increased over time. Mild stroke decreased over time. Conditions with warning, advanced age, limited life expectancy and family refusal were more common in women; mild stroke and rapid improvement were more common in men. Contraindications were more common in minorities; advanced age, mild stroke and rapid improvement, and family refusal were more common in non-Hispanic whites. When advanced age was selected, 46.6% of patients were over age 90 and 3.4% were under age 80. When stroke too mild was selected, 44.8% of patients had missing NIHSS scores, 42.1% of scores were 0-4, 8.8% were 5-9, and 4.3% were ≥ 10. The three most common reasons for not providing tPA were rapid improvement (40.9%), mild stroke (33.0%), and contraindications (29.2%) in 2010. Conclusions: More than half of ischemic stroke patients arriving within 2 hours of LKW were ineligible to receive IV tPA. There was little use of advanced age for patients under age 80. Documentation of stroke too mild was not substantiated by an NIHSS score in nearly half of patients. Better documentation of NIHSS score should be provided.

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Abstract TP69: Safety and Outcomes of IV Thrombolysis with Alteplase for Acute Ischemic Stroke Patients with Thrombocytopenia

Stroke ◽

10.1161/str.48.suppl_1.tp69 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Haris Kamal ◽

Nour Abdelhamid ◽

Liang Zhu ◽

Sean Savitz ◽

James Grotta ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Strong Evidence ◽

Demographic Data ◽

Categorical Variables ◽

Continuous Variables ◽

Chi Square ◽

Exact Test ◽

Chi Square Test ◽

Iv Tpa

Background: Intravenous tPA (IV tPA) has been the mainstay for reperfusion therapies for acute ischemic stroke (AIS) patients for 2 decades. Many contraindications from the initial NINDS trial were derived from experts’ consensus and not tested in the trial. Many AIS patients present with thrombocytopenia (< 100,000) and may be excluded from treatment in spite of lack of strong evidence. Some clinicians opt to treat these patients weighing the benefits and risks along with the lack of strong evidence behind this exclusion. We sought to evaluate the safety in AIS patients with low platelets receiving IV tPA as compared to those who do not. Methods: Restrospective chart review of all patients presenting with AIS between 1/2006 to 7/2016 at our center. We analyzed patients who had platelets <100,000 among this cohort and stratified them into those who were treated with IV tPA and those who received antiplatelet therapy only. Demographic data, medical history, medications, presence of sICH after treatment, presenting NIHSS were collected. Two sample Wilcoxon rank sum test was used to compare continuous variables between the two groups, and chi-square test or Fisher’s exact test used to compare categorical variables. Results: 21 patients were treated with IV tPA while 122 patients were treated with antiplatelets. Table 1 lists the demographic variables of the two groups with and without IV tPA. Patients included had moderate thrombocytopenia with very few <50,000. No significant differences were found in presenting NIHSS, race, gender, and history of atrial fibrillation between the two groups except platelets (p=0.0128), age (p=0.0462) and glucose (p=0.0279). Table 2 lists the outcome variables of mRS and symptomatic ICH. There was no petechial or sICH among 21 treated patients. Conclusion: While limited by small numbers and lack of randomization, our data suggest that IV tPA is safe in patients with moderately reduced platelet counts.

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Abstract WMP94: Temporal Trends in Racial, Age, and Sex-Specific Utilization of Decompressive Hemicraniectomy Among Acute Ischemic Stroke Patients in the United States

Stroke ◽

10.1161/str.51.suppl_1.wmp94 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sai P Polineni ◽

Fadar O Otite ◽

Seemant Chaturvedi

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Temporal Trends ◽

Age Groups ◽

The United States ◽

Decompressive Hemicraniectomy ◽

Study Results ◽

Over Time ◽

Age And Sex

Background: The aim of this study is to evaluate current trends in racial, age, and sex-specific utilization of decompressive hemicraniectomy (HC) in acute ischemic stroke (AIS) patients in the United States over the last decade. Methods: All adult patients with a diagnosis of AIS were identified from the 2004-2015 Nationwide Inpatient Sample (weighted N=4,792,428) using International Classification of Diseases Ninth revision (ICD-9) codes. Proportion of patients undergoing HC in various age, race, and sex groups were ascertained using ICD-9 procedural codes. Temporal trends were mapped by year in order to track changes in utilization over time. Analysis of utilization disparities and trends within age, sex, and race subgroups was conducted via multivariate logistic regression. Results: Of all eligible AIS patients from 2004-2015, 0.25% underwent HC (.08 in 2004 to .46 in 2015). Increased utilization over time was seen in both men (.13 to .57) and women (.08 to .54), with women showing comparable odds of utilization to men [OR: 0.95 (95% CI: .87-1.04, p=0.27)]. Similarly, increased utilization trends were seen in all age groups (Figure 1) with the highest rates in the 18-39 subgroup (1.41%). Compared to trends in this younger subgroup (.43 to 2.12), patients aged 60-79 experienced a similar overall increase but at lower utilization rates (.06 to .37). Compared to white patients in multivariate models, blacks did not show significant differences in odds of HC [1.09 (.96-1.24, p=0.20)], while patients from Hispanic [1.25 (1.03-1.51, p=0.02)] and other [1.26 (1.04-1.52, p=0.02)] race-ethnic groups showed increased odds. Conclusions: From 2004-2015, hemicraniectomy rates have seen substantial increases in all age, sex, and race groups. The increasing rates of hemicraniectomies among those over age 60 suggest that there has been at least partial acceptance of DESTINY 2 study results.

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Abstract 2545: Does Participation in a Stroke Registry Improve tPA Administration Rates?

Stroke ◽

10.1161/str.43.suppl_1.a2545 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Moges Ido ◽

Lydia Clarkson ◽

Deborah Camp ◽

Kerrie Krompf ◽

Michael Frankel

Keyword(s):

Quality Improvement ◽

Ischemic Stroke ◽

Length Of Stay ◽

Patient Care ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Hospital Size ◽

Stroke Registry ◽

Over Time ◽

Iv Tpa

Background: The purpose of the Georgia Coverdell Acute Stroke Registry (GCASR) is to improve the quality of patient care. GCASR conducts regular quality improvement activities to educate hospital staff and improve systems and processes. Administration of intravenous tissue plasminogen activator (IV tPA) is standard treatment for eligible acute ischemic stroke patients and can dramatically improve outcomes. Purpose: To determine whether GCASR hospitals were more likely to administer tPA to acute ischemic stroke patients than non-GCASR hospitals. Methods: Hospitalization data from acute care hospitals in Georgia was provided by the Georgia Hospital Association for November 2005 through December 2009. Acute ischemic stroke patients receiving tPA were identified using ICD-9 codes (433 and 434), procedure codes (9910), and healthcare common procedure system codes (J2997). A hospital was defined as a GCASR facility if it was actively participating in the registry at the time of patient hospitalization. A generalized estimating equation with robust variance estimation was applied using the SAS GLIMMIX procedure. “Hospital” was treated as a random variable. Relative risks for receiving tPA were estimated and adjusted for demographics, co-morbidities, hospital size, urbanicity, and length of stay. Results: A total of 55,403 patients were admitted with a principal diagnosis of acute ischemic stroke during the study period, and two percent (1,231) received tPA. Three percent of patients (871) seen at registry facilities received tPA, compared to 1.4% (360) of those seen at non-GCASR facilities. Age, gender, race, length of stay, hospital size, and participation in the registry all predicted tPA administration, either at or near significant levels (p-values from <0.0001 to 0.0646). Although IV tPA administration has increased over time in both hospital groups, patients treated at GCASR facilities were more likely to receive tPA after controlling for confounders (OR=1.64; 95% CI: 0.97-2.78), which approached significance (p=0.0646). Approximately 340 fewer people would have received tPA had all study patients been treated at non-GCASR facilities. Conclusions: Although all Georgia hospitals have improved their rate of tPA administration over time, GCASR hospitals maintained a higher rate than non-GCASR hospitals. This may be due in part to the quality improvement activities that registry facilities participate in and the assistance they receive. These results support the stroke registry model as a method of improving stroke patient care and outcomes.

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Abstract 16: IV TPA in the 0-3 Hour Window: Quantitative Fragility-Robustness Assessment of the Strength of the RCT Evidence

Stroke ◽

10.1161/str.52.suppl_1.16 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Katherine T Mun ◽

Jordan B Bonomo ◽

David S Liebeskind ◽

Jeffrey L Saver

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Individual Patient Data ◽

Endovascular Thrombectomy ◽

Strength Of Evidence ◽

Evidence Strength ◽

Meta Analyses ◽

Robustness Assessment ◽

Over Time ◽

Iv Tpa

Background: After 3 decades, the era of RCTs of IV tPA as a standalone therapy in acute ischemic stroke has now likely closed, with the completion of TESPI, PRISMS, and late, imaging-selection RCTs, and the advent of endovascular thrombectomy. Some non-expert contrarians questioned the accumulating evidence regarding tPA; the recently formulated fragility-robustness index (FRI) enables quantification of the actual rigor of evidence throughout the era of IV tPA investigation. Methods: The FRI summarizing the strength of the statistical evidence for clinical trial findings is the minimum nonevent to event changes needed to turn a statistically significant to non-significant result. The FRI was applied to disability-free (mRS 0-1) and independence (mRS 0-2) outcomes; cumulative meta-analyses delineated evidence strength after each successive RCT. FRI scores were classified: Not Robust (FRI 0-4), Somewhat Robust (5-12), Robust (13-33), and Highly Robust (>33). Results: Systematic search identified 8 RCTs (1960 patients) of IV tPA in the 0-3h window from 1995 - 2018. Study-level meta-analyses showed FRIs of 42 for mRS 0-1 and 40 for mRS 0-2; individual patient data meta-analyses showed FRIs of 40 for both mRS 0-1 and mRS 0-2, placing IV tPA in the highest quintile of FRIs among meta-analyses for all conditions. Evolution of RCT evidence over time is shown in Table 1. Strength of evidence for IV tPA superiority was already robust with publication of the initial 2 NINDS-tPA in 1995, remained robust through 2011 after 4 additional RCTs, increased to highly robust with the IST-3 mega-trial in 2012, and remains highly robust today after 1 additional trial. Conclusions: Intravenous tPA for acute ischemic stroke in 0-3h patients is one of the most robustly proven therapies in medicine. This therapy was already robustly supported with publication of the initial trials 25 years ago and advanced 9 years ago after additional trials to highly robust/non-fragile.

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Abstract P239: Trends in Ischemic Stroke Treatments and Mortality in the United States From 2012-2018

Stroke ◽

10.1161/str.52.suppl_1.p239 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Sharath Kumar Anand ◽

William J Benjamin ◽

Arjun Adapa ◽

Jiwon V Park ◽

Badih Daou ◽

...

Keyword(s):

Ischemic Stroke ◽

Private Health Insurance ◽

Systems Of Care ◽

Temporal Trends ◽

The United States ◽

First Line ◽

Chi Square ◽

Treatment Groups ◽

Stroke Systems Of Care ◽

Insurance Database

Introduction: The establishment of mechanical thrombectomy (MT) as a first line treatment for select patients with ischemic stroke (IS) and the resulting expansion of stroke systems of care have been major advancements in the care of IS patients. Our study aims to identify temporal trends in the usage of tPA and MT, as well as mortality for IS patients from 2012-2018. Hypothesis: We hypothesize that not only MT but also tPA utilization increased after 2015 compared to years previous, while mortality likely improved, given enhanced public education and optimization of stroke systems of care. Methods: Using a nation-wide, private health insurance database, we identified 141,959 patients who presented with a primary IS between 2012 and 2018. We evaluated trends in tPA and MT usage, and mortality stratified by treatment group using chi square and Cochran-Armitage testing. Results: Among patients presenting with IS in this population, the average age was 69.00 ± 12.23, and 47.43% were male. Between 2012-2018, the proportional use of tPA and MT increased significantly (tPA: 6.30%% to 11.79%, p<0.0001; MT: 1.57% to 5.69%, p<0.0001). Mortality at 30 days decreased significantly from 2012-2018 in the overall IS population (4.82% to 4.18%, p<0.0001). Mortality following MT saw the greatest improvement (30-day: 16.42% to 9.04%, p=0.0291), followed by tPA (30-day: 8.54% to 4.91%, p<0.0001) and finally by no treatment (30-day: 4.43% to 3.79%, p<0.0001). Conclusion: From 2012-18, we found the use of tPA and MT increased significantly while 30-day mortality decreased in the entire IS population. The most dramatic decrease in mortality was seen in the MT population, followed by tPA and no treatment groups.

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Abstract P215: Declining Gastrostomy Tube Utilization in Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p215 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Lee Pfaff ◽

Karen C Albright ◽

Julius Gene Latorre ◽

Fadar O Otite

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Age Groups ◽

Intravenous Thrombolysis ◽

International Classification Of Diseases ◽

Joinpoint Regression ◽

Peg Tube ◽

Demographic Subgroups ◽

Over Time ◽

Iv Tpa

Objective: To test the hypothesis that placement of percutaneous feeding tubes (PEG) in acute ischemic stroke (AIS) patients has declined following increased usage of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) over the last decade. Methods: We identified all primary adult AIS admissions contained in the 2005-2017 National Inpatient Sample using International Classification of Diseases (ICD) codes. Age and sex-specific proportions of hospitalizations with coexisting ICD procedural codes for PEG were computed. Joinpoint regression was used to evaluate trends over time. Multivariable adjusted logistic regression was used to compare odds of PEG use between periods and demographic subgroups. Results: From 2005-2017, 4.3% of all AIS hospitalizations had coexisting codes for PEG but usage differed by age, with highest proportion of usage in patients >=80 year old (y.o) (5.2%) and lowest frequency of usage in adults 18-39 y.o (2.7%). On joinpoint regression, there was no significant change in PEG use from 2005-2009, usage declined annually by -3.0% from 2009-2015 (95%CI -4.2% to -1.8%) and then declined sharply by -9.2% (95%CI -13.4 to -4.8%) from 2015 to 2017 (figure 1). The pace of decline was faster in patients >=80y.o compared to other age groups. After multivariable adjustment for clinical and hospital level factors, patients hospitalized in the period 2014-2017 had 25% reduced odds of PEG when compared to admissions in the period 2005-2009 (OR 0.76, 95%CI 0.72-0.79). Female sex and white race were associated with lower odds of PEG compared to males and black patients, respectively. IV-tPA and MT usage increased over time with marked increase in usage after 2015. Conclusion: Overall the rate at which PEG tube have been utilized has decreased significantly over the last decade. This decrease is likely from multifactorial advances in acute stroke (IV-tPA and MT) and post stroke neuro critical care.

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Abstract WMP32: Variation in the Rates of Acute Ischemic Stroke Transfers Between Hospitals in the United States

Stroke ◽

10.1161/str.47.suppl_1.wmp32 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Syed F Ali ◽

Gregg Fonarow ◽

Eric Smith ◽

Li Liang ◽

Robert Sutter ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

High Volume ◽

The United States ◽

Teaching Hospitals ◽

Large Sample Size ◽

Stroke Registry ◽

Intravenous Tissue Plasminogen Activator ◽

The Us ◽

Iv Tpa

Background: Many patients are transferred from emergency departments or inpatient units to stroke centers for advanced acute ischemic stroke (AIS) care, especially after intravenous tissue plasminogen activator (tPA). We sought to determine variation in the rates of AIS patient transfer in the US. Methods: Using data from the national Get With The Guidelines-Stroke registry, we analyzed AIS cases from 01/2010 to 03/14. Transfer-in was defined as transfer of AIS patients from other hospitals. Due to large sample size, instead of p-values, standardized differences were reported and a map of transfer-in rates across the US constructed. Results: Of the 970,390 patients discharged from 1,646 hospitals in the US, 87% were admitted via the ER or direct admission (front door) vs. 13% transferred-in. While most hospitals (61%) had transfer-in rates of < 5% of all AIS patients, a minority (17%) had high (>15%) transfer-in rates. High transfer-in hospitals were more often in the Midwest, were larger, and had higher annual AIS and IV tPA case volumes, and were also more often teaching hospitals and stroke centers (primary or comprehensive) (Table and Figure).. IV tPA was used more frequently in eligible patients in high-volume transfer-in hospitals (Table); otherwise, stroke quality of care was similar. Conclusions: There is significant regional- and state-level variability in the transfer of AIS patients. This may reflect differences in resource availability and the distribution of smaller, under-resourced hospitals that frequently transfer patients for advanced care after stabilization. Additional research is warranted to understand this variation.

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Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study

The Neuroradiology Journal ◽

10.1177/19714009211030526 ◽

2021 ◽

pp. 197140092110305

Author(s):

Chesney S Oravec ◽

Christine Tschoe ◽

Kyle M Fargen ◽

Carol A Kittel ◽

Alejandro Spiotta ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

High Volume ◽

Vessel Occlusion ◽

Decompressive Hemicraniectomy ◽

Rates Of Change ◽

Tissue Plasminogen ◽

Administration Rate ◽

Over Time

Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

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