Introduction: We created an optimized ELVO transfer protocol for PSCs focused on three key steps: early CSC notification based on clinical severity threshold, obtaining vessel imaging at the PSC, and cloud-based image sharing without the use of telemedicine.
Methods: Our regional PSC spokes were educated to execute the following protocol for patients presenting with a Los Angeles motor score ≥4: 1) notify the CSC on arrival 2) obtain CTA at time of initial NCCT and within 30 minutes of PSC arrival, and 3) implement a secure cloud-based remote viewing platform (LifeIMAGE). We reviewed all ICA and/or M1 occlusions transferred over an 11 month period, and divided the patients into two groups: those for whom the protocol was executed and those for whom it was not. Time from PSC arrival to start of angiogram was modeled using Kaplan-Meier estimation, with Wilcoxon test given no observations were censored. Favorable outcome (mRs 0-2 at 90 days) was modeled by protocol using a generalized linear model with a binary distribution.
Results: Between 7/1/15 to 5/31/16 there were 70 patients transferred for thrombectomy. When executed, the PSC ELVO protocol reduced the median time for PSC arrival to CSC groin puncture from 151 [141.0, 166.0] to 111 [88.0, 130.0] minutes, a significant reduction of 40 minutes, p<.0001. This was primarily related to improvement in PSC door in door out time which reduced from a median of 104 [82.0, 112.0] to 64 [51.0, 71.0] minutes, a reduction of 40 minutes, p<.0001. When the protocol was followed, patients were twice as likely to have a favorable outcome (50% vs. 25%), p<.05. No differences were observed for age (p=.52), travel distance (p=.94), NIHSS (p=.49), sex (p=.44), and IV tPA use (p=.93) between the two groups.
Conclusion: A standardized process at PSCs for suspected ELVO patients consisting of early CSC notification, CTA on arrival to the PSC and image sharing is easily implemented and significantly reduces the time to CSC groin puncture and improves outcomes.