title: Timing of vessel imaging for suspected large vessel occlusions does not affect groin puncture time in transfer patients with stroke.
abstract: BACKGROUND
  Access to endovascular therapy (ET) in cases of acute ischemic stroke may be limited, and rapid transfer of eligible patients to hospitals with endovascular capability is needed.
  
  
  OBJECTIVE
  To determine the optimal timing of diagnostic CT angiography to confirm large vessel occlusion (LVO).
  
  
  METHODS
  Of 57 emergency department transfers to Mount Sinai Hospital (MSH) for possible ET from January 2015 through March 2016, 39 (68%) underwent ET, among whom 22 (56%) had CT angiography before transfer and 17 (44%) had CT angiography on arrival. We compared mean outside hospital arrival to groin puncture (OTG) time between the two groups using t-tests and Wilcoxon rank sum tests. OTG was defined as the difference between groin puncture and outside hospital arrival time minus ambulance travel time.
  
  
  RESULTS
  Average age was 73±13 years and average National Institute of Health Stroke Scale score was 19±5. There was no difference in average OTG time between the two groups (191 min for CT angiography at outside hospital vs 190 min for CT angiography at MSH (p=0.99 for t-test and 0.69 for rank sum test)). Among the 18 patients who were transferred but did not receive ET, 10 had no LVO, 5 had large established infarcts on arrival and 3 had post-tissue plasminogen activator hemorrhage. In 9/10 patients without LVO, CT angiography was not performed before transfer.
  
  
  CONCLUSIONS
  CT angiography timing in the transfer process does not affect OTG time, but 90% of patients without LVO had not had CT angiography before transfer. Hence, it might be beneficial to obtain a CT angiogram at the outside hospital, if it can be acquired and read rapidly, to avoid the cost and potential clinical deterioration associated with unnecessary transfers.
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.|Department of Neurology, Divisions of Cerebrovascular Disease, Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
authors.forename: John W
authors.identifier: http://orcid.org/0000-0001-6055-0918
authors.initials: JW
authors.lastname: Liang
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Stein
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Natalie
authors.initials: N
authors.lastname: Wilson
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.|Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Johanna T
authors.initials: JT
authors.lastname: Fifi
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Stanley
authors.initials: S
authors.lastname: Tuhrim
authors.affiliation: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Mandip S
authors.initials: MS
authors.lastname: Dhamoon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D000072226:Computed Tomography Angiography / Q000379:methods* / Q000639:trends; D005260:Female; D006119:Groin / Q000098:blood supply / Q000000981:diagnostic imaging*; D006801:Humans; D008875:Middle Aged; D010360:Patient Transfer / Q000379:methods* / Q000639:trends; D011677:Punctures / Q000639:trends; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy; D061665:Time-to-Treatment / Q000639:trends; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage
chemical_list: D010959:Tissue Plasminogen Activator
keywords: Angiography; CT Angiography; Stroke; Thrombectomy