Interhospital transfer vs. direct presentation of patients with a large vessel occlusion not eligible for IV thrombolysis

Background and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT. Methods We used data from the MR CLEAN Registry (2014–2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders. Results Of the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p < 0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted β = − 51.6, 95% CI: − 64.0 to − 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted β = − 44.0, 95% CI: − 65.5 to − 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73–2.08). Conclusions In patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome.