• Charles Kircher, Amanda Humphries, Dawn Kleindorfer, Kathleen Alwell, Heidi Sucharew, Charles J Moomaw, Jason Mackey, Felipe De Los Rios La Rosa, Brett Kissela, and Opeolu Adeoye.
• University of Cincinnati (UC) Gardner Neuroscience Institute, Division of Neurocritical Care, Cincinnati OH, United States of America; UC Department of Emergency Medicine, 231 Albert Sabin Way, MSB 1654, Cincinnati, OH 45229, United States of America. Electronic address: charles.kircher@uc.edu.
• Am J Emerg Med. 2020 Dec 1; 38 (12): 265026522650-2652.

Background And PurposeAcute ischemic stroke (AIS) patients may benefit from endovascular thrombectomy (EVT) up to 24 h since last known normal (LKN). Advanced imaging is required for patient selection. Small or rural hospitals may not have sufficient CT technician and radiology support to rapidly acquire and interpret images. We estimated transfer rates using non-contrast head CT and stroke severity to select patients to be transferred to larger centers for evaluation.MethodsWe identified all AIS among residents of the study region in 2010. Only cases age ≥ 18 with baseline mRS 0-2 that presented to an ED were included. Among cases that presented between 6 and 24 h from LKN, those without evidence of acute infarct on head CT and with initial NIHSS ≥6 or ≥ 10 were identified.ResultsOf 1359 AIS cases, 448 (33.0%) presented between 6 and 24 h, of which 383 (85.5%) showed no evidence of acute infarct on CT. Of cases with no acute infarct on CT, 89/383 (23.2%) had NIHSS ≥6, of which 66 (74.2%) initially presented to a hospital without thrombectomy capabilities; and 51/383 (13.3%) had NIHSS ≥10, of which 40 (78.4%) presented to a non-thrombectomy hospital.ConclusionsIn our population, 40-66 AIS patients annually (0.8-1.3/week, or 3-5 patients/100,000 persons/year) may present to non-thrombectomy hospitals and need to be transferred using non-contrast CT and stroke severity as screening tools. Such an approach may sufficiently mitigate the impact of delays in treatment on outcomes, without overburdening the referring nor accepting hospitals.Copyright © 2020 Elsevier Inc. All rights reserved.

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