Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Jacob R. Morey, MBA; Xiangnan Zhang, MS; Naoum Fares Marayati, BA; Stavros Matsoukas, MD; Emily Fiano, MPH; Thomas Oxley, MD, PhD; Neha Dangayach, MD; Laura K. Stein, MD, MPH; Michael G. Fara, MD, PhD; Maryna Skliut, MD; Christopher Kellner, MD; Reade De Leacy, MD; J Mocco, MD; Stanley Tuhrim, MD; Johanna T. Fifi, MD

Disclosures

Stroke. 2021;52(9):e527-e530. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model.

Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale.

Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model (P<0.01). In the late window, outcomes were similar (35% versus 41%; P=0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window (P<0.01) and 5.0 and 11.0 in the late window (P=0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model (P<0.01) and similar in the late window (P=0.41).

Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03048292.

Introduction

Endovascular thrombectomy (EVT) has become the standard of care for acute ischemic stroke patients presenting with an emergent large vessel occlusion.[1] This time-sensitive intervention has historically been limited to comprehensive stroke centers (CSCs), resulting in 2 standard stroke delivery models: mothership and drip-and-ship (DS). In the mothership model, a patient is triaged directly to a CSC, while the DS model requires a transfer to a CSC from a primary stroke center (or other referring center), following potential intravenous thrombolysis.

Our health system consists of 1 CSC and 3 thrombectomy capable stroke centers, allowing for a novel stroke service delivery model that involves a Mobile Interventional Stroke Team (MIST) that travels from the CSC to a thrombectomy capable stroke center to perform EVT (Figures I and II in Data Supplement).[2] Our prospective observational cohort study revealed significantly improved initial door-to-skin puncture times and a greater proportion of patients with complete recovery at discharge, with no difference in clinical outcomes at 90 days for the overall population.[3] Based on research identifying fast versus slow stroke progressors, we hypothesized that in patients presenting within a last known well of ≤6 hours, the MIST model leads to improved clinical outcomes, as compared with the DS model.[4]

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