Bypassing the Closest Stroke Center Results in Worse Functional Outcomes for Intracerebral Hemorrhage
Published on: June 03, 2024
Original Article: Anna Ramos-Pachón, et al. Effect of Bypassing the Closest Stroke Center in Patients with Intracerebral Hemorrhage: A Secondary Analysis of the RACECAT Randomized Clinical Trial. JAMA Neurol. 2023;80(10):1028-1036.
Background
Intracerebral hemorrhage (ICH) constitutes around 15% of strokes, with high mortality and poor functional outcomes. Hematoma expansion causing neurological decline is a major concern, occurring in about 30% of patients within hours of onset. Factors exacerbating ICH outcomes include blood pressure variability, fever, hyperglycemia, and anticoagulation. Inpatient care bundles addressing these factors promptly can reduce mortality. This study hypothesized that prehospital transfer practices impact outcomes in the critical early phase of ICH. Given the efficacy of endovascular treatment (EVT) for large vessel occlusions (LVO), undifferentiated stroke patients may bypass local centers for EVT-capable ones. While EVT centers offer neurosurgical and neurocritical care for ICH, local centers can still promptly manage BP and coagulopathies. The impact of prehospital stroke triage on ICH patients is unclear. The authors of this trial performed a secondary analysis of RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) to investigate.
Methods
The RACECAT trial, conducted in Catalonia, Spain, aimed to optimize stroke triage strategies by comparing two approaches: "drip and ship," involving initial assessment at local centers with possible transfer for EVT, and direct transfer to EVT-capable centers ("mothership"). Participants were functionally independent patients with suspected LVO, excluding those requiring immediate life support. This analysis specifically investigated patients diagnosed with spontaneous ICH, excluding other stroke subtypes. The primary outcome was a shift analysis of functional outcome measured by modified Rankin Scale (mRS) scores at 90 days. Secondary outcomes included 24-hour, 5-day, and 90-day mortality, death or severe functional dependency (mRS 5-6), early neurological deterioration, ICH expansion, neurosurgical intervention, and rates of adverse events during transport and at day 5.
Results
This study analyzed 302 patients from the RACECAT trial diagnosed with spontaneous ICH. Mean age was 71.7 years, with 204 (67.5%) men and 98 (32.5%) women. No baseline characteristic differences were observed between groups. Among the study cohort, 137 (45.4%) were assigned to the intervention group, bypassing local centers for EVT-capable ones, resulting in delayed presentation by 135 minutes (IQR 97-184), averaging 46.8 minutes longer (95% CI, 14.0-80.8). Bypassing was associated with reduced odds of 90-day functional independence (adjusted common odds ratio, 0.63 per mRS shift). Secondary outcomes revealed higher odds of death or severe dependence (AOR, 1.72; 95% CI, 1.05-2.84), with pneumonia causing 19.4% of deaths in the EVT-capable group versus 8% in the local center group. EVT transfer was associated with more complications (22.6% vs 5.6%; AOR, 5.29; 95% CI, 2.38-11.73), primarily pneumonia (35.8% vs 17.6%). Additional sensitivity analyses confirmed worse outcomes, higher mortality, dependence, and more adverse events with EVT-center bypass.
Commentary
In this secondary analysis of the RACECAT trial, patients with subsequent ICH diagnosis who bypassed local stroke centers for EVT-capable ones had worse functional outcomes, with these results also supported by additional sensitivity analyses. EVT center transfers experienced more adverse events, primarily pneumonia, likely due to the 46.8-minute longer transit, which may have increased the risk of neurological deterioration, vomiting, and aspiration.
ICH represents ~15% of all strokes, and in the RACECAT trial, it constituted 21.5% of potential LVOs. Considering prehospital ischemic stroke triage's impact on this substantial ICH subset within undifferentiated strokes is crucial. While the study’s findings support implementation of emergency ICH care at local centers, limited data on management variations, including withdrawal of care, hampers its ability to draw firm conclusions. Additionally, most EVT centers in Catalonia were >30 minutes away, possibly limiting generalizability to urban areas. The study also lacked comprehensive ICH representation by including only severe cases (RACE score >4), while limited follow-up neuroimaging (~50%) prevented accurate hematoma expansion assessment. Nevertheless, these findings raise important questions about prehospital triage practices and whether mobile stroke units with hyperacute CTs may allow for immediate differentiation, appropriate triage, and bifurcation of management strategies for ischemic versus hemorrhagic strokes.
Author Affiliations
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Neurocritical Care Fellow, Johns Hopkins Hospital