Ultra-Long Transfers for Endovascular Thrombectomy-Mission Impossible?: The Australia-New Zealand Experience

Carlos Garcia-Esperon; Teddy Y Wu; Vinicius Carraro do Nascimento; Bernard Yan; Craig Kurunawai; Tim Kleinig; Gregory Selkirk; David Blacker; P Alan Barber; Annemarei Ranta; Alvaro Cervera; Andrew Wong; Peter Mitchell; Claire Muller; Hal Rice; Laetitia De Villiers; Jim Jannes; Jae Beom Hong; Peter Bailey; Helen Brown; Bruce C V Campbell; Duncan Wilson; John Fink; Timothy Ang; Christopher Bladin; Tim Phillips; Md Golam Hasnain; Kenneth Butcher; Ferdinand Miteff; Christopher R Levi; Neil J Spratt; Mark W Parsons; ANZ Ultra-Long EVT Transfer Group

doi:10.1161/STROKEAHA.122.040480

Ultra-Long Transfers for Endovascular Thrombectomy-Mission Impossible?: The Australia-New Zealand Experience

Stroke. 2023 Jan;54(1):151-158. doi: 10.1161/STROKEAHA.122.040480. Epub 2022 Nov 23.

Authors

Carlos Garcia-Esperon^{1

2

3}, Teddy Y Wu⁴, Vinicius Carraro do Nascimento⁵, Bernard Yan⁶, Craig Kurunawai⁷, Tim Kleinig⁷, Gregory Selkirk⁸, David Blacker⁸, P Alan Barber⁹, Annemarei Ranta^{10

11}, Alvaro Cervera¹², Andrew Wong¹³, Peter Mitchell¹⁴, Claire Muller¹³, Hal Rice⁵, Laetitia De Villiers⁵, Jim Jannes⁶, Jae Beom Hong⁹, Peter Bailey¹⁵, Helen Brown¹³, Bruce C V Campbell^{10

11}, Duncan Wilson⁴, John Fink⁴, Timothy Ang¹⁶, Christopher Bladin^{17

18}, Tim Phillips⁷, Md Golam Hasnain^{2

3}, Kenneth Butcher^{19

17}, Ferdinand Miteff^{1

2

3}, Christopher R Levi^{1

2

3}, Neil J Spratt^#^{1

2

3}, Mark W Parsons^#^{3

4

20}; ANZ Ultra-Long EVT Transfer Group

Collaborators

ANZ Ultra-Long EVT Transfer Group:
Beng Lim Alvin Chew, Mary Morgan, Wayne Collecutt, Martin Krauss, Aaron Tan, Joshua Mahadevan, Matthew Willcourt, Alvaro Cervera, Andrew Bivard

Affiliations

¹ Department of Neurology, John Hunter Hospital, Australia (C.G.-E., F.M., C.R.L., N.J.S.).
² College of Health, Medicine, and Wellbeing, University of Newcastle, Australia (C.G.-E., M.H., F.M., C.R.L., N.J.S., M.W.P.).
³ Hunter Medical Research Institute, Newcastle, Australia (C.G.-E., M.H., F.M., C.R.L., N.J.S., M.W.P.).
⁴ Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W., D.W., J.F., M.W.P.).
⁵ Department of Interventional Neuroradiology, Gold Coast University Hospital, Australia (V.C.d.N., H.R., L.D.V.).
⁶ Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (B.Y., J.J.).
⁷ Royal Adelaide Hospital, Australia (C.K., T.K., T.P.).
⁸ Neurology Department, Charles Gairdner Hospital, Perth, Australia (G.S., D.B.).
⁹ Department of Medicine, The University of Auckland, New Zealand (P.A.B., J.B.H.).
¹⁰ Department of Neurology, Wellington Hospital, New Zealand (A.R., B.C.V.C.).
¹¹ Department of Medicine, University of Otago, Wellington, New Zealand (A.R., B.C.V.C.).
¹² Royal Darwin Hospital, Darwin, Australia (A.C.).
¹³ Department of Neurology, Royal Brisbane and Women's Hospital, Australia (A.W., C.M., H.B.).
¹⁴ Department of Radiology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (P.M.).
¹⁵ Department of Neurology, Gold Coast University Hospital, Gold Coast, Australia (P.B.).
¹⁶ Department of Interventional Neuroradiology, Royal Prince Alfred hospital, Sydney, Australia (T.A.).
¹⁷ Florey Institute of Neuroscience and Mental Health, Australia (C.B., B.K.).
¹⁸ Eastern Health Clinical School, Monash University, Victoria, Australia (C.B.).
¹⁹ Prince of Wales Clinical School, Sydney, Australia (K.B.).
²⁰ University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, Australia (M.W.P.).

^# Contributed equally.

PMID: 36416128
DOI: 10.1161/STROKEAHA.122.040480

Abstract

Background: Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial; however, the magnitude and best imaging strategy at the referring center remains uncertain. We hypothesized that patients transferred >300 miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale [mRS] score of 0-2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS.

Methods: This is a retrospective analysis of patients transferred from 31 referring hospitals >300 miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021).

Results: There were 131 patients; the median age was 64 [53-74] years and the median baseline National Institutes of Health Stroke Scale score was 16 [12-22]. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 [1-3] versus 3 [1-6] in the patients selected with noncontrast CT+CT angiography, P=0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 [0.01-0.19]; P<0.01).

Conclusions: In selected patients transferred >300 miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.

Keywords: magnetic resonance imaging; neuroimaging; reperfusion; stroke; thrombectomy.

MeSH terms

Brain Ischemia* / therapy
Endovascular Procedures* / methods
Humans
Middle Aged
New Zealand
Retrospective Studies
Stroke* / diagnostic imaging
Stroke* / surgery
Thrombectomy / methods
Treatment Outcome