Intravenous thrombolysis at primary stroke centers versus comprehensive stroke centers: Analysis from the AcT trial

IntroductionFast delivery of intravenous thrombolysis (IVT) and transportation to a comprehensive stroke center (CSC) is paramount in primary stroke centers (PSCs), to achieve effective reperfusion. We investigated clinical outcomes and workflow times of patients treated with IVT at PSCs. MethodologyThis is a secondary analysis of the AcT trial, a multicenter, phase-3, randomized, controlled, noninferiority trial comparing tenecteplase with alteplase in patients with acute ischemic stroke within 4.5 hours of onset. We compared baseline characteristics, imaging and clinical outcomes at 90 days, and workflow times between PSCs and CSCs. ResultsOf 1577 patients enrolled in the trial, 99 (6.27%) were treated at PSCs and 1,478 (93.72%) at CSCs. Both groups had similar age (median 72 [64 - 82] versus 74 [63 - 83] years), proportion of females (42.42% versus 48.24%), baseline stroke severity (median National Institute of Health Stroke Scale 9 [6 - 16] versus 10 [6 - 16.5] points) and presence of large vessel occlusion (24.24% versus 24.70%). The proportion of patients achieving excellent functional outcome at 90 days was significantly higher in PSCs compared to CSCs (mRS 0-1: 48.48% versus 35.01%, adjusted IRR, 1.42 [CI 95%, 1.04 - 1.95]), without differences in safety outcomes. Patients treated at PSCs had longer onset-to-needle (median, 139 [100 - 190] versus 128 [94 - 185] minutes, p 0.026) and door-to-needle times (median, 56.5 [42 - 70] versus 35 [27 - 47] minutes, p <0.001). In the 24 patients transferred from PSCs to CSCs, those who received tenecteplase had lower needle-to-puncture times compared to those who received alteplase (median, 35.5 [21 - 58] versus 52 [18 - 74] minutes, p <0.001). ConclusionsDespite less efficient workflows for IVT and similarities in baseline characteristics, the proportion of patients treated at PSCs who had excellent functional outcomes was higher compared to CSCs. Patients who received tenecteplase prior to CSC transfer had more efficient time metrics when compared to those who received alteplase.