Spoke‐Administered Thrombolysis Improves Large‐Vessel Occlusion Early Recanalization: The Real‐World Experience of a Large Academic Hub‐and‐Spoke Telestroke Network

Abstract

Background Intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for large‐vessel occlusion (LVO) stroke is increasingly controversial. Recent trials suggest MT without IVT is reasonable for patients presenting directly to MT‐capable “hub” centers. However, bypassing IVT has not been evaluated for patients presenting to IVT‐capable “spoke” hospitals that require hub transfer for MT. A perceived lack of efficacy of IVT to result in LVO early recanalization (ER) is often cited to support bypassing IVT, but data for IVT in patients who require interhospital transfer are limited. Here, we examined LVO ER rates after spoke‐administered IVT in our hub‐and‐spoke stroke network. Methods Patients presenting to 25 spokes before hub transfer for MT consideration from 2018 to 2020 were retrospectively identified from a prospectively maintained database. Inclusion criteria were pretransfer computed tomography angiography–defined LVO, Alberta Stroke Program Early Computed Tomography Score ≥6, and posttransfer repeat vessel imaging. Results Of 167 patients, median age was 69, and 51% were women. Seventy‐six received spoke IVT, and 91 did not. Alteplase was the only IVT used in this study. Comorbidities and National Institutes of Health Stroke Scale were similar between groups. ER frequency was increased 7.2‐fold in patients who received spoke IVT (12/76 [15.8%] versus 2/91 [2.2%]; P <0.001]. Spoke‐administered IVT was independently associated with ER (adjusted odds ratio, =11.5 [95% CI, 2.2–99.6; P <0.05) after adjusting for the timing of last known well, interhospital transfer, and repeat vessel imaging. Interval National Institutes of Health Stroke Scale score was improved in patients with ER (median −2 [interquartile range, −6.3 to −0.8] versus 0 [−2.5 to 1]; P <0.05). Conclusion Within our network, patients who received spoke IVT had a 7.2‐fold increased ER relative likelihood. This real‐world analysis supports IVT use in eligible patients with LVO at spoke hospitals before hub transfer for MT.