Research Article| Volume 29, ISSUE 6, 104689, June 2020

Time Intervals for Direct Versus Transfer Cases of Thrombectomy for Stroke in a Primarily Rural System of Care


      Background: Early treatment is the key to a successful recovery for ischemic stroke patients. From time of onset, a patient's chances of permanent disability only increase until they can receive reperfusion intervention. Objective: We sought to identify potential delays that occur during evaluation and treatment of patients in a rural regional health system. Methods: We conducted a single-center retrospective review of all patients that arrived at our comprehensive stroke center (CSC) between July 2011 and March 2017, and received thrombectomy, with or without prior treatment with intravenous recombinant tissue plasminogen activator. Results: One hundred and fifty-four patients met our criteria for inclusion. Patients were divided into 2 groups: Direct (patients brought to our CSC from scene) and Transfer (patients taken to an outside hospital then transferred to our CSC). The median time to CSC for Direct patients was 82 (range: 15-863) minutes after onset of symptoms, compared to 237 (range: 98-1215) minutes for the Transfer group. The median time for Transfer patients to reach an outside hospital was 74 (range: 5-840) minutes, with an additional average time of 90 minutes in the outside hospital prior to transferred to our CSC. Conclusions: Based on our findings, patients brought directly to our CSC saved a significant amount of time, which may improve functional outcomes. Both groups (Direct and Transfer) spent a similar amount of time between last known normal and emergency medical services arrival, highlighting the need for increased awareness among the public to activate the stroke system of care.

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        • Benjamin E.J.
        • Go Alan S
        • Arnett Donna K
        • et al.
        Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association.
        Circulation. 2016; 133: e38-360
        • Benjamin E.J.
        • Blaha M.J.
        • Chiuve S.E.
        • et al.
        Heart disease and stroke statistics—2017 update: a report from the American Heart Association.
        Circulation. 2017; 135: e146-e603
      1. National Center for Health Statistics. Stats of the State of Kentucky. Available at: Accessed April 11, 2018

        • Jovin T.G.
        • Chamorro A.
        • Cobo E.
        • et al.
        Thrombectomy within 8 hours after symptom onset in ischemic stroke.
        N Engl J Med. 2015; 372: 2296-2306
        • Gonzales S.
        • Mullen M.T.
        • Skolarus L.
        • et al.
        Progressive rural-urban disparity in acute stroke care.
        Neurology. 2017; 88: 441-448
        • Shultis W.
        • Graff R.
        • Chamie C.
        • et al.
        Striking rural-urban disparities observed in acute stroke care capacity and services in the pacific northwest: implications and recommendations.
        Stroke. 2010; 41: 2278-2282
        • Fang J.
        • Yan W.
        • Jiang G.X.
        • et al.
        Time interval between stroke onset and hospital arrival in acute ischemic stroke patients in Shanghai, China.
        Clin Neurol Neurosurg. 2011; 113: 85-88
        • Prabhakaran S.
        • Ward E.
        • John S.
        • et al.
        Transfer delay is a major factor limiting the use of intra-arterial treatment in acute ischemic stroke.
        Stroke. 2011; 42: 1626-1630
        • Morris D.L.
        • Rosamond W.D.
        • Hinn A.R.
        • et al.
        Time delays in accessing stroke care in the emergency department.
        Acad Emerg Med. 1999; 6: 218-223
        • Kodankandath T.V.
        • Wright P.
        • Power P.M..
        • et al.
        Improving transfer times for acute ischemic stroke patients to a comprehensive stroke center.
        J Stroke Cerebrovasc Dis. 2017; 26: 192-195
        • Davis A.F.
        Kentucky's Urban/Rural Landscape: What is driving the differences in wealth across Kentucky.
        Kentucky Annual Economic Report. 2009; : 25-34
        • Koifman J.
        • Hall R.
        • Li S.
        • et al.
        The association between rural residence and stroke care and outcomes.
        J Neurol Sci. 2016; 363: 16-20
        • Danzl M.M.
        • Hunter E.G.
        • Campbell S.
        • et al.
        "Living with a ball and chain": the experience of stroke for individuals and their caregivers in rural Appalachian Kentucky.
        J Rural Health. 2013; 29: 368-382
        • Albers G.W.
        • Marks M.P.
        • Kemp S.
        • et al.
        Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.
        N Engl J Med. 2018; 378: 708-718
        • Desai S.M.
        • Rocha M.
        • Molyneaux B.J.
        • et al.
        Thrombectomy 6-24 hours after stroke in trial ineligible patients.
        J Neurointerv Surg. 2018; 10: 1033-1037
        • Fischer U.
        • Arnold M.
        • Nedeltchev K.
        • et al.
        NIHSS score and arteriographic findings in acute ischemic stroke.
        Stroke. 2005; 36: 2121-2125
        • Schlegel D.
        • Kolb S.J.
        • Luciano J.M.
        • et al.
        Utility of the NIH stroke scale as a predictor of hospital disposition.
        Stroke. 2002; 34: 134-137
        • Weimar C.
        • Konig I.R.
        • Kraywinkel K.
        • et al.
        Age and National Institutes of Health stroke scale score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models.
        Stroke. 2004; 35: 158-162