– José G. Merino, MD
Early Transfer of Stroke Patients to Comprehensive Stroke Centers: David and Goliath
This month’s Stroke controversy addresses whether patients with moderately severe stroke should be transferred to a comprehensive stroke center (CSC) in the acute stage or whether the transfer can be done later if complications develop or more complex issues arise. Drs. Kevin Sheth and Peter Langhorne, the two panelists, present their views on the need to transfer a 55 year old man with 75% left carotid artery stenosis who presents with a left MCA syndrome and NIHSS score of 20 five hours after symptom onset.
Dr. Seth argues for early transfer even if the patient is outside the time window for a reperfusion therapy because he is at high risk for neurologic deterioration and the staff at a CSC may closely monitor him to identify any complications and intervene in a timely manner if necessary. The staff at a CSC may also implement secondary stroke prevention strategies early on, including carotid endarterectomy for this patient. Dr. Langhorne, on the other hand, maintains that an ambulance ride will not help the patient and that many small hospitals can care for the patient as long as they have a well-run stroke unit. He reminds us that a stroke unit admission is the only intervention proven to improve survival after stroke and maintains that staff in a stroke unit should be able to monitor for complications and institute secondary prevention measures. If carotid endarterectomy is not available at the smaller hospital, the patient may be transferred to a larger center within the first two weeks after the stroke.
Both authors address the possible need for a hemicraniectomy if the patient develops significant brain swelling but disagree in terms of the risk in a patient with an NIHSS score of 20 and, if an intervention is needed, the timing when the neurosurgical team should get involved.
In a Solomonic discussion, Drs. Molina and Selim, the moderators of the debate, acknowledge the validity of the issues raised by the debaters. They conclude that system and patient factors play a role in the decision to transfer a patient, and suggest that telemedicine is a way to make the decision easier. I agree with them. Well organized primary stroke centers must have the infrastructure required for managing most patients in the acute stage. The decision to transfer a patient to a comprehensive stroke center must take into account availability of local resources, the condition of the patient, the expertise of the treatment team and, ideally, the advice of the stroke specialists at the CSC. The way forward cannot be prescriptive.
If neither one is doing anything to stop the neuronal cascade of death there seems to be no reason for a move.