P-023 Spoke-administered intravenous alteplase and outcomes for large vessel occlusion stroke patients in a hub-and-spoke telestroke model
Bibliographic record
Abstract
Introduction The role of intravenous alteplase treatment for emergent large vessel occlusion (ELVO) stroke patients who ultimately undergo endovascular thrombectomy (EVT) has been questioned in recent randomized trials. However, most patients enrolled in these trials presented directly to an EVT-capable hub center (i.e. ‘mothership’ model). We aimed to compare outcomes for ELVO patients transferred to our hub for EVT consideration who were administered alteplase at spoke hospitals (i.e. ‘drip and ship’ model) versus those who were not. Methods ELVO stroke patients who presented to 25 spoke hospitals from January 1, 2018 to June 30, 2020 were retrospectively identified from a prospectively maintained database. Inclusion criteria were transfer for EVT consideration, spoke hospital CTA-defined ELVO, and spoke hospital Alberta stroke program early CT score (ASPECTS) ≥6. ELVO was defined as occlusion of the internal carotid artery terminus, first or second segment of the middle cerebral artery, or basilar artery. Outcomes of interest included adequate reperfusion (TICI 2b-3), any intracerebral hemorrhage (ICH), hub discharge functional independence (modified Rankin scale, mRS ≤2), and 90-day mRS ≤2. Results Inclusion criteria were met for 258 patients. Their median age was 70 years (IQR 60-81), median NIHS stroke scale (NIHSS) was 13 (6-19), and 50% were female. 38% were treated with alteplase at spoke hospitals, and there were no significant differences in baseline characteristics comparing those treated and those not treated except for last known well-to-Telestroke consult time (median 1.6 vs 6.7 hours, p<0.0001). 44% ultimately underwent EVT at the hub with 87% achieving TICI 2b-3. Spoke-administered alteplase was not associated with ICH (OR=1.042, 95%CI=0.390,2.784, p=0.935) and trended toward association with greater TICI 2b-3 (OR=3.589, 95%CI=0.940,13.70, p=0.062). Spoke-administered alteplase independently increased the odds of discharge mRS ≤2 (aOR=2.568, 95%CI=1.159,5.686, p=0.020) and 90-day mRS ≤2 (aOR=3.307, 95%CI=1.591,6.874, p=0.001), even when controlling for last known well, NIHSS, and EVT in multivariable models. Conclusion In this cohort of 258 patients who first presented to spoke hospitals as potential EVT candidates with CTA-defined ELVO and ASPECTS ≥6, treatment with intravenous alteplase at spoke hospitals before transfer significantly increased the odds of discharge and 90-day functional independence without increasing the odds of ICH. Intravenous alteplase should not be withheld from ELVO patients who first present to spoke hospitals capable of its administration but requiring transfer for EVT. Additional studies are warranted to confirm benefits of spoke-administered alteplase in other hub-and-spoke models and to understand the minimum distance and transfer time associated with benefit. Disclosures R. Regenhardt: None. J. Rosenthal: None. A. Awad: None. N. Nolan: None. J. McIntyre: None. C. Whitney: None. N. Alotaibi: None. J. Vranic: None. C. Stapleton: None. A. Patel: None. N. Rost: None. L. Schwamm: None. T. Leslie-Mazwi: None.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".