In patients with intracranial hemorrhage (ICH), bypassing the closest stroke center and going directly to an endovascular treatment (EVT)-capable stroke center led to reduced chances of functional independence 3 months later, according to a secondary analysis of data from the RACECAT trial.

Direct transfer to an endovascular center was also associated with higher mortality. Moreover, ICH patients directly transferred to an endovascular center had a roughly fivefold higher risk of experiencing medical complications and a 2.6-fold higher chance of in-hospital pneumonia.

“To the best of our knowledge, the present study provides the first data from a randomized clinical trial about the effect of different prehospital transport protocols among patients experiencing ICH,” write Anna Ramos-Pachón, MD, of Hospital Germans Trias, Catalonia, Spain, and colleagues.

Commenting on the study for Medscape Medical News, Babak Navi, MD, MS, chief of the Division of Stroke and Hospital Neurology and director of the Stroke Center, Weill Cornell Medicine, New York City, said the findings “should entreat clinician and governmental stakeholders to critically appraise their protocols for the prehospital transport of stroke patients, particularly the downstream effects of bypassing the closest stroke center for patients with suspected LVO [large vessel occlusion] ultimately diagnosed as having ICH.”

The study was published online August 21 in JAMA Neurology.

“Drip and Ship” vs “Mothership”

Prehospital transfer pathways are designed to achieve rapid access to endovascular centers because, in patients with LVO stroke, endovascular treatment is associated with superior outcomes, compared with intravenous thrombolysis alone, and the benefit of EVT is “strongly time dependent,” the researchers write.

However, these protocols don’t take into account the effect on non-LVO stroke patients. In particular, “the effect of regionalized LVO stroke care on patients who receive a final diagnosis of ICH is unknown,” the authors observe.

The previously reported RACECAT study compared two routing strategies: “drip and ship,” or transfer to the nearest local stroke center, the reference intervention; and “mothership,” or transfer to the nearest endovascular center, bypassing the local stroke center, the experimental intervention. The main results of that study showed no significant difference between these strategies on 90-day neurological outcomes.

The current study, a secondary analysis of that earlier trial, focused specifically on patients ultimately diagnosed with spontaneous ICH (n = 302, 67.5% male, mean age 71.7 years), with a median Rapid Arterial Occlusion Evaluation (RACE) score of 7.

Of these, 137 were transported to a “mothership,” while 165 were transported to the closest local stroke center. Demographic and ICH characteristics (including stroke severity, ICH volume, and ICH location) were similar between the groups. A total of 37 patients initially brought to a local center were subsequently transferred to a center with endovascular capability.

The primary outcome was a shift analysis of disability at 90 days, based on the modified Rankin Scale (mRS), with scores ranging from 0 (no symptoms) to 6 (death).

Secondary outcomes included 90-day mortality, a composite outcome of death or severe functional dependency (mRS score of 5 or 6), rate of clinical complications during initial transport, rate of adverse events until day 5 (neurological deterioration, seizure, and pneumonia), and a composite outcome (death or severe functional dependency).

Specific Circumstances

The median distance from stroke onset scene to first hospital was 12.6 km for local stroke centers and 88.8 km for endovascular centers, while the median time from symptom onset to first hospital arrival of 94 minutes vs 135 minutes, respectively — a mean difference of 46.8 (95% CI, 14.0 – 80.8) minutes.

Direct transfer to an endovascular center resulted in worse functional outcomes at 90 days, compared with transfer to the nearest stroke center (mean mRS score 4.93 vs 4.66, respectively; adjusted odds ratio, 0.63; 95% CI, 0.41 – 0.96), as well as higher 90-day mortality, medical complications during initial transfer, and in-hospital pneumonia.

RACECAT Subanalysis: Outcomes By Transfer Protocol  

Pneumonia was implicated in 19.4% of the deaths in the EVT-capable stroke center group vs 8% of the deaths in the local stroke center group.

The odds of the composite outcome were roughly 70% higher in the endovascular center group vs the local stroke center group (aOR, 1.72; 95% CI, 1.5 – 2.84).

On the other hand, despite a mean transport difference of 46.8 minutes, no differences in baseline vital signs and stroke severity on arrival to the first center were found. Moreover, blood pressure levels on admission, baseline ICH volume, radiologic markers of growth, and hematoma enlargement were also similar.

“These results suggest new therapeutic targets to improve ICH outcomes, such as early prevention of vomiting or pneumonia, that potentially could be applied in the prehospital setting,” the authors suggest.

The results of the current study, together with the main findings of RACECAT, “suggest that generalized bypass transfer protocols for patients with severe stroke symptoms located in areas not primarily covered by an EVT-capable stroke center should be considered only in specific circumstances,” they state.

Improving Prehospital Triage Accuracy

Navi, co-author of an accompanying editorial, noted that it was conducted in Catalonia, Spain, a mostly nonurban setting. “Therefore, future trials in urban settings and different countries are needed to validate the results,” he said.

But the study does indicate that patients with ICH “do better when they are quickly stabilized at local stroke centers, and therefore better diagnostic tools are needed to accurately differentiate ICH from LVO ischemic stroke in the field,” Navi added.

The authors agree. They note that prehospital triage algorithms suggest routing patients based on results of prehospital stroke severity scales. “However, our results examining this strategy highlight the need to improve the accuracy of prehospital triage among patients with stroke.”

They recommend that prehospital differential diagnosis between ischemic stroke and ICH “should become a priority as an evolution of the present LVO-centered EMS protocols.”

Future research “should focus on the improvement of prehospital stroke scales, the validation of new simple and reliable prehospital technologies, and the implementation of early point-of-care biomarkers.”

JAMA Neurol. Published online August 21, 2023. Abstract, Editorial

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counselling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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