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Updated: Aug 2, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular
Alexander Kuc1, Derek L Isenberg2, Chadd K Kraus3
1Department of Emergency Medicine, Cooper University Hospital, United States of America.
Insights
Transferring large vessel occlusion stroke patients to endovascular stroke centers takes too long. Non-certified stroke centers and delays in vascular imaging increase transfer times, while thrombolysis can reduce them.
Area of Science:
- Neurology
- Cardiovascular Diseases
- Public Health
Background:
- Large vessel occlusion stroke (LVOS) management often involves transfer from non-endovascular to endovascular stroke centers (ESCs).
- Door-in-door-out (DIDO) time is a critical benchmark, but evidence-based guidelines are lacking.
- Optimizing transfer times is crucial for improving patient outcomes in LVOS.
Purpose of the Study:
- To identify factors influencing DIDO times in LVOS patients undergoing endovascular treatment (EVT).
- To provide insights for improving inter-facility transfer efficiency for stroke care.
Main Methods:
- Analysis of the OPUS-REACH registry (2015-2020) including LVOS patients transferred to nine ESCs in the Northeast US.
- Univariate analysis using t-tests and multivariate logistic regression to identify factors associated with DIDO times.
Main Results:
- Mean DIDO time was 137.8 minutes.
- Vascular imaging and non-certified stroke center status were associated with significantly longer DIDO times (23 and 14 minutes longer, respectively).
- Intravenous thrombolysis administration was associated with a 15-minute reduction in DIDO time.
Conclusions:
- Vascular imaging acquisition and non-stroke certified centers prolong DIDO times.
- Non-ESCs should integrate vascular imaging into workflows to expedite transfers.
- Further research into transfer logistics (e.g., air vs. ground) may reveal additional improvement opportunities.
Introduction:
In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT.
Methods:
The Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio.
Results:
511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC.
Discussion:
Vascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.
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