Evaluation Of Exclusions For Endovascular Intervention To Identify Clinical Practice Patterns

Background: Our five-hospital Comprehensive Stroke Program utilizes a standardized large vessel occlusion (LVO) triage that includes NIHSS >10 and last known well <6 hours. When these criteria are met, the ED Physician and Neuro-interventionalist determine endovascular thrombectomy (ET) eligibility. If ET is not performed, standardized exclusion criteria is documented Purpose: To evaluate patterns in exclusions for ET and identify opportunities to expand treatments. Methods: A retrospective chart review of patients who arrived within 6 hours of symptom onset over a 4- month period was conducted. Patients were divided into two groups: those who received ET and those who did not. Documented exclusions were evaluated to identify clinical practice patterns. Results: Of the 52 patients who arrived within 6 hours of symptom onset, 81% (n=42) did not receive ET. Fifty-seven percent (n=24) were excluded due to deficits too mild (NIHSS < 10) and 43% (n=18) had NIHSS > 10 with documented exclusions. Exclusions included 1) Lack of LVO 56% (n=10); 2) Rapid improvement or mild symptoms 6% (n=1); 3) Refusal by the patient/family 11% (n=2); 4) Other reasons documented by the physician 27% (n=4). Other reasons included CTP findings of complete infarct (1), poor collaterals with large clot extension (1), unable to access common carotid occlusion (2). None of the patients were excluded due to elevated creatinine or advanced age. Exclusions were documented by 1) Neuro-interventionalist 72% (n=13;) 2) ED Physician 6% (n=1;) 3) Primary Care 6% (n=1); 4) Radiology CTA report 16% (n=3). Conclusions: The most common reasons for ET exclusion in our cohort are non-modifiable: absence of LVO and unfavorable imaging characteristics. We identified patient/family refusal as a less common exclusion reason but one that may warrant education. Continued data collection is needed to further understand exclusion patterns and improve identification of patients that could benefit from ET.