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Original Investigation
May 8, 2017

Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes

Author Affiliations
  • 1Department of Diagnostic Imaging, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
  • 2Department of Neurology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
  • 3Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
  • 4The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island
  • 5Lifespan Biostatistics Core, Rhode Island Hospital, Providence
JAMA Neurol. Published online May 8, 2017. doi:10.1001/jamaneurol.2017.0477
Key Points

Question  For patients suspected of having emergent large-vessel occlusion (ELVO) who present to a primary stroke center (PSC), can a standardized protocol that is based on (1) early notification to the closest comprehensive stroke center (CSC), (2) computed tomographic angiography at the PSC, and (3) electronic image sharing prior to transfer improve efficiency and outcomes?

Findings  In this cohort study, when the PSC protocol was fully executed, the rate of good outcomes was doubled and the time from arrival at the PSC to reperfusion at the CSC was almost 1 hour less than that with only a partial execution of the protocol.

Meaning  This protocol can be easily replicated between PSC and CSC partners and may improve stroke care delivery for patients with ELVO presenting to centers without endovascular capability.


Importance  While prehospital triage to the closest comprehensive stroke center (CSC) may improve the delivery of care for patients with suspected emergent large-vessel occlusion (ELVO), efficient systems of care must also exist for patients with ELVO who first present to a primary stroke center (PSC).

Objective  To describe the association of a PSC protocol focused on 3 key steps (early CSC notification based on clinical severity, vessel imaging at the PSC, and cloud-based image sharing) with the efficiency of care and the outcomes of patients with suspected ELVO who first present to a PSC.

Design, Setting, and Participants  In this retrospective cohort study, 14 regional PSCs unfamiliar with the management of patients with ELVO were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher: (1) notify the CSC on arrival, (2) perform computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival, and (3) share imaging data with the CSC using a cloud-based platform. A total of 101 patients were transferred from regional PSCs to the CSC between July 1, 2015, and May 31, 2016, and received mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into 2 groups based on whether the PSC protocol was partially or fully executed.

Main Outcomes and Measures  The primary outcomes were efficiency measures including time from PSC door in to PSC door out, time from PSC door to CSC groin puncture, and 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome).

Results  Although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%) (mean age, 77 years [interquartile range, 65-84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age, 76 years [interquartile range, 59-86 years]; 13 of the 22 patients [59.1%] were women). When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture (from 151 minutes [95% CI, 141-166 minutes] to 111 minutes [95% CI, 88-130 minutes]; P < .001). This was primarily related to an improvement in the time from PSC door in to door out that reduced from a median time of 104 minutes (95% CI, 82-112 minutes) to a median time of 64 minutes (95% CI, 51-71.0 minutes) (P < .001). When the protocol was fully executed, patients were twice as likely to have a favorable outcome (50% vs 25%, P < .04).

Conclusions and Relevance  When fully implemented, a standardized protocol at PSCs for patients with suspected ELVO consisting of early CSC notification, computed tomographic angiography on arrival to the PSC, and cloud-based image sharing is associated with a reduction in time to groin puncture and improved outcomes.