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Leading Neurointerventionalists Say New Insights on TRIAGE-STROKE and RACECAT Affirm Benefits of Direct Transport to CSCs for ELVO Patients
JNIS Commentary Urges Hospital Systems to Follow the Evidence and Prioritize Patient Outcomes
FAIRFAX, Va. — In an Editor’s Column published in the Journal of NeuroInterventional Surgery (JNIS), leaders of the Society of NeuroInterventional Surgery (SNIS) conclude that the entire body of research, including evidence from two new prospective trials, clearly confirm that most patients with emergent large vessel occlusions (ELVO) will benefit from triage directly to comprehensive stroke centers (CSCs).
JNIS editors are urging hospital stakeholders to understand that data from two recent, concurrent and seemingly negative trials —TRIAGE-STROKE and RACECAT— actually both provide confirmatory evidence that a direct triage program, as endorsed by the National Association of State EMS Officials, where patients with emergent large vessel occlusion (ELVO) are transported directly to comprehensive stroke centers (CSCs), is beneficial for patients in most geographies in the United States and worldwide.
Since the release of this prospective data earlier this year, SNIS leaders say trade media and select hospital systems have issued messaging proclaiming, without qualification, that direct triage programs are ineffective. This has caused concerns about risks to patient care and outcomes in the neurointerventional community.
“Misinterpreting both studies — which were stopped early — poses a grave risk to our patients in the U.S. and much of the international community,” said David Fiorella, MD, lead author of the commentary, Director of the Stony Brook Cerebrovascular Center and senior member of SNIS. “We’ve begun to see the effects, with some primary stroke centers (PSCs) and hospital systems leveraging perceived financial incentives to interrupt lifesaving, direct-to-CSC triage policies.”
Thrombectomy Capable Centers (TCCs) in Europe are the equivalent of CSCs in the U.S. The authors say RACECAT studied a very large, diffusely populated, non-urban geography in Catalonia, Spain, where all TCCs are clustered in Barcelona — a system structure that is vastly different than much of the U.S. The majority (56%) of patients triaged directly to a TCC required >60 minutes of transport time, having little relevance to most of the U.S. population who live within one hour or less of a TCC or CSC. Moreover, the EMS providers in Catalonia were not capable of “administering treatment,” unlike the treatment capabilities of U.S.-based EMS, which further exacerbated the detrimental effects of prolonged transport times to farther facilities.
The authors of TRIAGE-STROKE reported data overwhelmingly in favor of direct triage to a CSC for ELVOs, but given its small study population, it failed to reach statistical significance. The data on IV lytic administration also supported previous studies that demonstrate that excess transportation time required to get to a CSC does not diminish access to lytic therapy. Of additional significance, the study found evidence that the risk of dependence or death was higher for stroke patients triaged to a PSC first, rather than directly to a CSC, whether they had an ELVO or not.
Globally, mechanical thrombectomy is not only considered effective for eligible patients, but firmly established as the standard of care for ELVO patients. However, the efficacy of such stroke therapies is largely dependent on time to treatment, and not all stroke centers are equipped to treat these patients, further emphasizing the need for quick and appropriate protocols.
“Much of the neurointerventional field is alarmed that these studies are being aggressively and inappropriately applied to interrupt or prevent direct transport programs from being implemented,” said SNIS President Mahesh Jayaraman, MD. “We must continue to apply triage and transport models that are proven to save lives. These are life and death decisions, and it is our duty as care providers to prioritize patient outcomes over additional profits.”
About the Society of NeuroInterventional Surgery
The Society of NeuroInterventional Surgery (SNIS) is a scientific and educational association dedicated to advancing the specialty of neurointerventional surgery through research, standard-setting, and education and advocacy to provide the highest quality of patient care in diagnosing and treating diseases of the brain, spine, head and neck. Since 2016, SNIS and its members have worked to improve patient outcomes for stroke patients through its Get Ahead of Stroke® advocacy and education campaign. Visit www.snisonline.org and follow us on Twitter (@SNISinfo) and Facebook (@SNISOnline).
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