Mechanical Thrombectomy After Inter-Hospital Transfer: A Narrative Review of Door-In-Door-Out Time as a Quality Measure
DOI:
https://doi.org/10.5281/zenodo.22227700Keywords:
Acute Ischaemic Stroke, Mechanical Thrombectomy, Door-In-Door-Out Time, Interhospital Transfer, Stroke Systems of CareAbstract
Most patients who need mechanical thrombectomy do not arrive at a hospital that can perform it. They arrive somewhere else
first, and what happens in that first emergency department, between the doors, decides much of what the procedure can still
achieve.
Objectives: To review the published evidence on door-in-door-out time in acute stroke: how long it actually takes, how that
compares with the recommended target, what determines it, who waits longest, and what the evidence establishes about its
relationship to outcome.
Material and Methods: Narrative review of randomised trials, individual patient data meta-analyses, national registry analyses,
single-network cohorts and society guidance indexed in PubMed and the major stroke and neurointervention journals. No new
patient data were generated; every estimate quoted is one published by the original investigators.
Results: Across 108,913 transfers from 1925 hospitals, the median door-in-door-out time was 174 minutes (IQR 116 to 276) and
only 27.3 per cent of patients met the recommended target of 120 minutes or less. Among patients transferred specifically for
endovascular therapy the median was 132 minutes. Longer times were associated with age 80 or older (14.9 additional minutes),
non-Hispanic Black ethnicity (8.2), Hispanic ethnicity (5.4) and female sex (5.2). Individual centres have reported medians of 86
minutes, and 59 minutes within working hours. Thrombectomy itself achieved functional independence in 46 per cent against 27
per cent with medical therapy alone within six hours.
Conclusion: The interval is long, highly variable, and demonstrably compressible, since some centres achieve less than half the
national median with the same technology. It is also the part of the pathway with no clinical work in it: the decision has been
made and the patient is waiting. Whether shortening it improves outcomes has not been tested randomly, and the observational
evidence is confounded by severity in both directions.
Abbreviations: AIS – Acute Ischaemic Stroke, DIDO – Door-In-Door-Out, ED – Emergency Department, EVT – Endovascular
Thrombectomy, LVO – Large Vessel Occlusion, mRS – Modified Rankin Scale, cOR – Common Odds Ratio, IQR – Interquartile
Range.
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