Paolo Passadore, Simona Carella, Marcello Naccarato, Giulia Sajeva, Alessio Pieroni, Sandro Zambito, Giulio Bozzato, Domenico Idone, Giampietro Zanette, Anna Maria Basile, Roberta Padoan, Federica Viaro, Adriana Critelli, Salvatore Lanzafame, Paola Caruso, Giampietro Ruzza, Morena Cadaldini, Giovanni Merlino, Manuel Cappellari, Bruno Giometto, Antonella De Boni, Michele Morra, Alessandro Campagnaro, Antonio Baldi, Matteo Atzori, Simone Tonello, Agnese Tonon, Simone Lorenzut, Martina Bruno, Roberto Bombardi, Elisabetta Menegazzo, Emanuele Turinese, Bruno Bonetti, Franco Ferracci, Francesco Paladin, M. Turazzini, Luca Zanet, Marco Simonetto, Alberto Polo, Bruno Marini, Elisa Corazza, Paolo Bovi, Monia Russo, Stefano Forlivesi, Silvia Vittoria Guidoni, Anna Gaudenzi, Valeria Bignamini, Roberto L’Erario, Maela Masato, Alessandro Burlina, Carmine Tamborino, Francesco Perini, Cappellari, M., Bonetti, B., Forlivesi, S., Sajeva, G., Naccarato, M., Caruso, P., Lorenzut, S., Merlino, G., Viaro, F., Pieroni, A., Giometto, B., Bignamini, V., Perini, F., De Boni, A., Morra, M., Critelli, A., Tamborino, C., Tonello, S., Guidoni, S. V., L'Erario, R., Russo, M., Burlina, A., Turinese, E., Passadore, P., Zanet, L., Polo, A., Turazzini, M., Basile, A. M., Atzori, M., Marini, B., Bruno, M., Carella, S., Campagnaro, A., Baldi, A., Corazza, E., Zanette, G., Idone, D., Gaudenzi, A., Bombardi, R., Cadaldini, M., Lanzafame, S., Ferracci, F., Zambito, S., Ruzza, G., Simonetto, M., Menegazzo, E., Masato, M., Padoan, R., Bozzato, G., Paladin, F., Tonon, A., and Bovi, P.
It is not known whether the current territorial organization for acute revascularization treatments in ischemic stroke patients guarantees similar time to treatment and functional outcomes among different levels of institutional stroke care. We aimed to assess the impact of time to treatment on functional outcomes in ischemic stroke patients who received intravenous thrombolysis (IVT) alone, bridging (IVT plus thrombectomy), or primary thrombectomy in level 1 and level 2 Stroke Units (SUs) in Triveneto, a geographical macroarea in Northeast of Italy. We conducted an analysis of data prospectively collected from 512 consecutive ischemic stroke patients who received IVT and/or mechanical thrombectomy in 25 SUs from September 17th to December 9th 2018. The favorable outcome measures were mRS score 0–1 and 0–2 at 3months. The unfavorable outcome measures were mRS score 3–5 and death at 3months. We estimated separately the possible association of each variable for time to treatment (onset-to-door, door-to-needle, onset-to-needle, door-to-groin puncture, needle-to-groin puncture, and onset-to-groin puncture) with 3-month outcome measures by calculating the odds ratios (ORs) with two-sided 95% confidence intervals (CI) after adjustment for pre-defined variables and variables with a probability value ≤ 0.10 in the univariate analysis for each outcome measure. Distribution of acute revascularization treatments was different between level 1 and level 2 SUs (p < 0.001). Among 182 patients admitted to level 1 SUs (n = 16), treatments were IVT alone in 164 (90.1%), bridging in 12 (6.6%), and primary thrombectomy in 6 (3.3%) patients. Among 330 patients admitted to level 2 SUs (n = 9), treatments were IVT alone in 219 (66.4%), bridging in 74 (22.4%), and primary thrombectomy in 37 (11.2%) patients. Rates of excellent outcome (51.4% vs 45.9%), favorable outcome (60.1% vs 58.7%), unfavorable outcome (33.3% vs 33.8%), and death (9.8% vs 11.3%) at 3months were similar between level 1 and 2 SUs. No significant association was found between time to IVT alone (onset-to-door, door-to-needle, and onset-to-needle) and functional outcomes. After adjustment, door-to-needle time ≤ 60min (OR 4.005, 95% CI 1.232–13.016), shorter door-to-groin time (OR 0.991, 95% CI 0.983–0.999), shorter needle-to-groin time (OR 0.986, 95% CI 0.975–0.997), and shorter onset-to-groin time (OR 0.994, 95% CI 0.988–1.000) were associated with mRS 0–1. Shorter door-to-groin time (OR 0.991, 95% CI 0.984–0.998), door-to-groin time ≤ 90min (OR 12.146, 95% CI 2.193–67.280), shorter needle-to-groin time (OR 0.983, 95% CI 0.972–0.995), and shorter onset-to-groin time (OR 0.993, 95% CI 0.987–0.999) were associated with mRS 0–2. Longer door-to-groin time (OR 1.007, 95% CI 1.001–1.014) and longer needle-to-groin time (OR 1.019, 95% CI 1.005–1.034) were associated with mRS 3–5, while door-to-groin time ≤ 90min (OR 0.229, 95% CI 0.065–0.808) was inversely associated with mRS 3–5. Longer onset-to-needle time (OR 1.025, 95% CI 1.002–1.048) was associated with death. Times to treatment influenced the 3-month outcomes in patients treated with thrombectomy (bridging or primary). A revision of the current territorial organization for acute stroke treatments in Triveneto is needed to reduce transfer time and to increase the proportion of patients transferred from a level 1 SU to a level 2 SU to perform thrombectomy.