• Cerebrovascular Disease
• Neurology Clinical Trials

• Neurology
• Cerebrovascular Disease
• Neurology Clinical Trials

Evan Allen, MD, MBA, Florida Hospital Neuroscience Institute, Orlando, Florida, USA, described the benefits of a state-wide severe stroke adjusted triage (SAST) system that bypasses a geographically-closer primary stroke center (PSC) for treatment at a comprehensive stroke center (CSC).

The rationale for the SAST system involved the knowledge that, while the chance of complete recovery from severe stroke improves with treatment like injection of tissue plasminogen activator (t-PA) that can be done at many PSCs, overall treatment success is low [Adams HP Jr. et al. Stroke 2007].

The SAST bypass system legislated in Florida requires emergency medical services (EMS) providers to transport suspected stroke patients to a CSC capable of administering t-PA, rather than to the nearest PSC.

Dr. Allen reported the results of a 7-year (2006–2012) retrospective analysis of therapeutic bypass yield (percentage of patients receiving treatments not available at the bypassed PSC), diagnostic accuracy of EMS providers, and outcome effect of bypassing a PSC located closer to the site of stroke. The analysis involved suspected acute strokes that occurred in the Orlando region and were ultimately treated at Florida Hospital Orlando CSCs in Orange County (Table 1).

Of the 526 patients, 77 (15%, ∼1 in 7 patients) received CSC-specific interventions that included acute endovascular intervention for ischemic stroke (7.5%), neurosurgery for intracranial bleeding (5%), neurosurgery for intracranial tumor (2%), and other procedures including aneurysm coiling and extra-intra cranial arterial bypass (0.5%). Comparison of therapeutic bypass yields for patients who suffered stroke and trauma revealed 15% (77/526) of stroke patients received CSC-specific care and 18% (35/193) of trauma patients received surgery within 48 hours at a Level 1 trauma center. The difference was not statistically significant (OR, 0.77; 95% CI, 0.5 to 1.2).

Comparative analyses of data for 643 patients who were transported directly to a single PSC for treatment and 209 SAST bypass patients treated at the CSC revealed the potential benefit in the bypass triage strategy. CSC patients experienced significantly higher rates of major complications and fatal/debilitating intracerebral hemorrhage (Table 2), which were immediately treatable at the CSC as opposed to transferring a patient from the PSC to a CSC for treatment.

The results indicate the potential benefit of the SAST bypass system. In-field identification of patients with severe stroke-like symptoms enables these patients to receive prompt treatment available at a CSC.

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