Automated Large Vessel Occlusion Detection Software and Thrombectomy Treatment Times: a Cluster Randomized Clinical Trial

IMPORTANCE: The benefit of endovascular stroke therapy (EVT) in large vessel occlusion (LVO) ischemic stroke is highly time dependent. Process improvements to accelerate in-hospital workflows are critical. OBJECTIVE: to determine whether automated computed tomography (CT) angiogram interpretation coupled with secure group messaging can improve in-hospital EVT workflows. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized stepped-wedge clinical trial took place from January 1, 2021, through February 27, 2022, at 4 comprehensive stroke centers (CSCs) in the greater Houston, Texas, area. All 443 participants with LVO stroke who presented through the emergency department were treated with EVT at the 4 CSCs. Exclusion criteria included patients presenting as transfers from an outside hospital (n = 158), in-hospital stroke (n = 39), and patients treated with EVT through randomization in a large core clinical trial (n = 3). INTERVENTION: Artificial intelligence (AI)-enabled automated LVO detection from CT angiogram coupled with secure messaging was activated at the 4 CSCs in a random-stepped fashion. Once activated, clinicians and radiologists received real-time alerts to their mobile phones notifying them of possible LVO within minutes of CT imaging completion. MAIN OUTCOMES AND MEASURES: Primary outcome was the effect of AI-enabled LVO detection on door-to-groin (DTG) time and was measured using a mixed-effects linear regression model, which included a random effect for cluster (CSC) and a fixed effect for exposure status (pre-AI vs post-AI). Secondary outcomes included time from hospital arrival to intravenous tissue plasminogen activator (IV tPA) bolus in eligible patients, time from initiation of CT scan to start of EVT, and hospital length of stay. In exploratory analysis, the study team evaluated the impact of AI implementation on 90-day modified Rankin Scale disability outcomes. RESULTS: Among 243 patients who met inclusion criteria, 140 were treated during the unexposed period and 103 during the exposed period. Median age for the complete cohort was 70 (IQR, 58-79) years and 122 were female (50%). Median National Institutes of Health Stroke Scale score at presentation was 17 (IQR, 11-22) and the median DTG preexposure was 100 (IQR, 81-116) minutes. In mixed-effects linear regression, implementation of the AI algorithm was associated with a reduction in DTG time by 11.2 minutes (95% CI, -18.22 to -4.2). Time from CT scan initiation to EVT start fell by 9.8 minutes (95% CI, -16.9 to -2.6). There were no differences in IV tPA treatment times nor hospital length of stay. In multivariable logistic regression adjusted for age, National Institutes of Health Stroke scale score, and the Alberta Stroke Program Early CT Score, there was no difference in likelihood of functional independence (modified Rankin Scale score, 0-2; odds ratio, 1.3; 95% CI, 0.42-4.0). CONCLUSIONS AND RELEVANCE: Automated LVO detection coupled with secure mobile phone application-based communication improved in-hospital acute ischemic stroke workflows. Software implementation was associated with clinically meaningful reductions in EVT treatment times. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05838456

Women With Large Vessel Occlusion Acute Ischemic Stroke Are Less Likely to Be Routed to Comprehensive Stroke Centers

Background Prehospital routing of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) to centers capable of performing endovascular therapy may improve clinical outcomes. Here, we explore whether distance to comprehensive stroke centers (CSCs), stroke severity, and sex are associated with direct‐to‐CSC prehospital routing in patients with LVO AIS. Methods and Results In this cross‐sectional study, we identified consecutive patients with LVO AIS from a prospectively collected multihospital registry throughout the greater Houston area from January 2019 to June 2020. Primary outcome was prehospital routing to CSC and was compared between men and women using modified Poisson regression including age, sex, race or ethnicity, first in‐hospital National Institutes of Health Stroke Scale score, travel time, and distances to the closest primary stroke center and CSC. Among 503 patients with LVO AIS, 413 (82%) were routed to CSCs, and women comprised 46% of the study participants. Women with LVO AIS compared with men were older (73 versus 65, P<0.01) and presented with greater National Institutes of Health Stroke Scale score (14 versus 12, P=0.01). In modified Poisson regression, women were 9% less likely to be routed to CSCs compared with men (adjusted relative risk [aRR], 0.91 [0.84–0.99], P=0.024) and distance to nearest CSC ≤10 miles was associated with 38% increased chance of routing to CSC (aRR, 1.38 [1.26–1.52], P<0.001). Conclusions Despite presenting with more significant stroke syndromes and living within comparable distance to CSCs, women with LVO AIS were less likely to be routed to CSCs compared with men. Further study of the mechanisms behind this disparity is needed