Australian clinicians have made the case for remote patients to undertake the “Mission Impossible” of ultra-long transfers for endovascular thrombectomy, reporting benefits in select patients travelling 500km and beyond for care.

The argument follows an analysis of the records of 163 Australian and New Zealand patients air transferred over 300 miles (483km) for EVT, including a number who made the 3000km trip from Darwin to Adelaide.

Patients travelled a median distance of 1022km to their treating comprehensive stroke centres (CSC), mostly from small hospitals, and the median time of brain ischaemia was prolonged at 12.6 hours.

But the researchers found the journey was usually worth it and a high proportion achieved functional independence and independent mobility at three months after the stroke – similar to rates reported at comprehensive stroke centres internationally.

“This retrospective data compiled from nine CSC from two different countries suggests that patients from remote areas can achieve a high rate of good outcome with EVT regardless of the initial distance to the CSC,” wrote Dr Carlos Garcia-Esperon and colleagues in Stroke (link here).

At baseline, 60% had non-contrast CT+CT angiography, while 40% also had CTP.

Once transferred, 87% underwent cerebral angiography and 73% proceeded to EVT.

In those followed to three months, almost half (48%) had an mRS score of 0-2 and 63% had a score of 0-3.

Furthermore, patients selected with CTP were less likely to have a large ischaemic core volume at arrival to the CSC, the researchers found.

They said that finding came amidst “considerable controversy” around the role of CTP in acute stroke selection “with suggestions that CTP may exclude some patients who might still benefit from treatment and cherry-picks those patients who are more likely to have an excellent outcome”.

“These might be opinions to consider for those patients presenting in the early time window and at the CSC,” they wrote.

“Nonetheless, our results support the notion that CTP is useful prior to ultra-long transfers, which are onerous, delayed, and expensive.”

CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months, coming at a median on the scale of 2 versus 3 in the patients selected with non-contrast CT+CT angiography.

However, patients selected with CTP were less likely to have an mRS score of 5 to 6.

“Notably, 20.3% of the patients lysed at the referring site had recanalized on arrival at the CSC,” the researchers added.

“As CTP now can be used to support thrombolysis beyond 4.5 hours, this may be even more relevant in a rural setting, as rural patients tend to present to the local emergency department later compared to metropolitan dwellers.”

The researchers concluded: “We suggest that these results support the role of perfusion imaging capability in remote stroke centers, especially in geographically large telestroke networks.”

“Through efficient and sustainable pathways to identify and transfer appropriate large vessel occlusion patients, there is a major opportunity to improve outcomes for stroke patients even in very remote locations.”