Disparities in the Use of Mechanical Thrombectomy Alone Compared with Adjunctive Intravenous Thrombolysis in Acute Ischemic Stroke in the United States

Background and Purpose: Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy. Methods: We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses. Results: Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%–48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%–35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%–16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25–0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%–28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%–69.9%) of urban patients. For 93.8% (95% CI, 93.6%–94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%–76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity. Conclusions: We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.

Download Full-text

Medical Specialties of Clinicians Providing Mechanical Thrombectomy to Patients With Acute Ischemic Stroke in the United States

JAMA Neurology ◽

10.1001/jamaneurol.2017.5172 ◽

2018 ◽

Vol 75 (4) ◽

pp. 515 ◽

Cited By ~ 7

Author(s):

Hooman Kamel ◽

Caroline D. Chung ◽

Gbambele J. Kone ◽

Ajay Gupta ◽

Nicholas A. Morris ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The United States ◽

Medical Specialties

Download Full-text

Solitaire Flow Restoration Thrombectomy for Acute Ischemic Stroke

Neurosurgery ◽

10.1227/01.neu.0000429859.96652.57 ◽

2013 ◽

Vol 73 (1) ◽

pp. 19-26 ◽

Cited By ~ 41

Author(s):

Maxim Mokin ◽

Travis M. Dumont ◽

Erol Veznedaroglu ◽

Mandy J. Binning ◽

Kenneth M. Liebman ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Strong Predictor ◽

Intravenous Thrombolysis ◽

The United States ◽

Nihss Score ◽

Fda Approval ◽

Flow Restoration ◽

Solitaire Fr

Abstract BACKGROUND: The promising results of the Solitaire Flow Restoration (FR) With the Intention for Thrombectomy (SWIFT) trial recently led to Food and Drug Administration (FDA) approval of the Solitaire FR stent retriever device for recanalization of cerebral vessels in patients with acute ischemic stroke. OBJECTIVE: To report the early postmarket experience with this device since its FDA approval in the United States, which has not been previously described. METHODS: We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between March 2012 and July 2012 at 10 United States centers where the Solitaire FR was used as a single device or in conjunction with other intraarterial endovascular approaches. RESULTS: A total of 101 patients were identified (mean age, 64.7 years; mean admission National Institutes of Health Stroke Scale [NIHSS] score, 17.6). Intravenous thrombolysis was administered in 39% of cases; other endovascular techniques were utilized in conjunction with the Solitaire FR in 52%. Successful recanalization (Thrombolysis in Myocardial Infarction 2/3) was achieved in 88%. The rate of symptomatic intracranial hemorrhage within the first 24 hours was 15%. In-hospital mortality was 26%. At 30 days, 38% of patients had favorable functional outcome (modified Rankin scale score ⩽2). Severity of NIHSS score on admission was a strong predictor of poor outcome. CONCLUSION: Our study shows that a variety of other endovascular approaches are used in conjunction with Solitaire FR in actual practice in the United States. Early postmarket results suggest that Solitaire FR is an effective tool for endovascular treatment of acute ischemic stroke.

Download Full-text

Readmissions After Mechanical Thrombectomy for Acute Ischemic Stroke in the United States: A Nationwide Analysis

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2018.05.035 ◽

2018 ◽

Vol 27 (10) ◽

pp. 2632-2640 ◽

Cited By ~ 2

Author(s):

Preethi Ramchand ◽

Dylan P. Thibault ◽

James A. Crispo ◽

Joshua Levine ◽

Robert Hurst ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The United States

Download Full-text

Trends in Endovascular Mechanical Thrombectomy in Treatment of Acute Ischemic Stroke in the United States

World Neurosurgery ◽

10.1016/j.wneu.2020.03.105 ◽

2020 ◽

Vol 138 ◽

pp. e839-e846 ◽

Cited By ~ 2

Author(s):

Isobel E.R. MacKenzie ◽

Iman Moeini-Naghani ◽

Dimitri Sigounas

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The United States ◽

Endovascular Mechanical Thrombectomy

Download Full-text

Mechanical Thrombectomy in Acute Ischemic Stroke Patients Performed Within and Outside Clinical Trials in the United States

Neurosurgery ◽

10.1093/neuros/nyz359_s24 ◽

2020 ◽

Vol 87 (Supplement_1) ◽

pp. S24-S24

Author(s):

Adnan I Qureshi ◽

Baljinder Singh ◽

Wei Huang ◽

Zhiyuan Du ◽

Iryna Lobanova ◽

...

Keyword(s):

United States ◽

Clinical Trials ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The United States ◽

Stroke Patients

Download Full-text

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

Stroke ◽

10.1161/strokeaha.121.035853 ◽

2021 ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Eric E. Smith ◽

Jeffrey L. Saver ◽

Mathew J. Reeves ◽

...

Keyword(s):

United States ◽

Quality Improvement ◽

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Phase I ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

The United States

Background and Purpose: The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. Methods: We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010–2013) and Target: Stroke Phase II (2014–2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Results: Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60–98) preintervention, to 66 minutes (51–87) during Phase I, and 50 minutes (37–66) during Phase II ( P <0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% ( P <0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% ( P <0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014–2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31–2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64–0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62–0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38–1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. Conclusions: A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Download Full-text