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Post-transfer reassessment for endovascular treatment: factors associated with changes in EVT eligibility

· DOI: 10.1186/s42466-026-00539-8

stroke deep-dive endovascular-treatment interhospital-transfer observational-cohort

Reconstructed on October 14, 2026 for the missed October 10 publication slot. This is a replacement article, not a recovered original. The source was present in the archived briefing for October 10, 2026.

Clinical Question (PICO)

Among adults with anterior-circulation large-vessel occlusion transferred from a primary stroke center for endovascular treatment (EVT), which clinical or baseline-imaging features were associated with repeat-imaging evidence of complete recanalization or extensive infarct progression?[1] This retrospective cohort did not assign a treatment or compare routine with selective rescanning; it studied associations in patients who all underwent reassessment.[1]

Bottom Line

Of 200 transferred patients, 19 (9.5%) had a repeat-imaging change the authors classified as affecting EVT eligibility: complete recanalization in 10 (5.0%) and ASPECTS 0–3 progression in 9 (4.5%).[1] Arrival neurologic change and baseline CTA source-image ASPECTS were associated with these events, but the rare outcomes, observational design, and single-network setting do not validate a transfer triage rule or show that selective imaging improves outcomes.[1]

Design

  • Study type: Retrospective observational cohort from a prospectively maintained registry; no randomization or assigned intervention.[1]
  • N: 200 analyzed from 883 transferred patients assessed for eligibility; the Results text says 1,389 patients were initially assessed, while Figure 1 displays 1,369.[1]
  • Setting and period: One comprehensive stroke center coordinating a regional German stroke network; transfers from January 2016 through December 2020.[1]
  • Assessment: Baseline and post-transfer non-contrast CT/CTA plus NIHSS at both hospitals; two neuroradiologists independently reviewed imaging, with consensus and automated analysis used to resolve disagreements.[1]
  • Primary outcomes: Complete recanalization on repeat CTA and extensive infarct progression, defined as ASPECTS 0–3 on repeat non-contrast CT; complete-case Firth penalized logistic regression addressed the small event counts.[1]
  • Timing: Median transfer duration was 148 minutes (IQR 119–173), and median onset-to-imaging at the comprehensive center was 233 minutes (IQR 196–316).[1]

Population

Inclusion Criteria

  • Adults with anterior-circulation LVO transferred for EVT evaluation, with baseline primary-center CT/CTA, repeat CT/CTA immediately after transfer, and NIHSS documented at both hospitals.[1]
  • During this 2016–2020 cohort period, transferred patients had baseline non-contrast CT ASPECTS of at least 5; all had CTA-confirmed anterior-circulation LVO.[1]

Exclusion Criteria

  • Posterior-circulation stroke, incomplete imaging datasets, or missing NIHSS documentation.[1]

Baseline Characteristics

  • Median age 77 years (IQR 67–83); 88/200 (44.0%) were men.[1] Median NIHSS at the referring hospital was 16 (IQR 11–19), baseline non-contrast CT ASPECTS 9 (IQR 8–10), CTA source-image ASPECTS 7 (IQR 6–9), and collateral score 2 (IQR 1–2).[1]
  • Intravenous thrombolysis was given to 112/200 (56.0%); alteplase was the standard agent in this historical cohort.[1]

Interventions

No intervention was randomized.[1] The exposures of interest were neurologic change during transfer, baseline CTASI ASPECTS and collateral status, and intravenous thrombolysis.[1] Repeat non-contrast CT and CTA were obtained after transfer in the analyzed cohort; there was no routine-imaging-versus-selective-imaging comparison.[1]

Outcomes

The authors reported these event counts and multivariable Firth-model estimates.[1] Odds ratios for NIHSS change are per one-point increase in the referring-hospital NIHSS minus the arrival NIHSS; positive values therefore indicate improvement.[1] These associations are not validated prediction thresholds.[1]

Outcome or factor Estimate Interpretation / qualification
Complete recanalization on repeat CTA 10/200 (5.0%) Eligibility-changing event reported by the authors.
IV thrombolysis and complete recanalization OR 4.87 (95% CI 1.08–46.25); P=0.039 Adjusted association; wide interval.
NIHSS change and complete recanalization OR 1.09 (1.00–1.18); P=0.059 Direction favored improvement, but not statistically significant at the authors’ threshold.
Extensive infarct progression, ASPECTS 0–3 9/200 (4.5%) Repeat non-contrast CT outcome.
NIHSS change and progression OR 0.83 (0.70–0.97); P=0.018 Adjusted association per one-point higher improvement-coded change.
Baseline CTA source-image ASPECTS and progression OR 0.55 (0.34–0.79); P=0.001 Adjusted association per one-point higher score.
Collateral score and progression OR 0.33 (0.08–1.14); P=0.080 Same direction, not statistically significant.
Transfer duration OR 1.00 (0.98–1.01), P=0.84 for recanalization; OR 1.00 (0.98–1.01), P=0.78 for progression No association detected in this selected, rapidly transferred cohort; this does not establish that time is unimportant.
Exploratory carotid/tandem vs M1 occlusion Recanalization OR 0.11 (0.001–0.88), P=0.034; progression OR 3.26 (0.89–12.56), P=0.074 Univariable exploratory analysis; only seven patients had M2 occlusions.

Among the 190 patients without complete recanalization, 103 had received thrombolysis; the authors emphasize that thrombolysis alone was not a specific trigger.[1] Functional outcomes after a selective reassessment strategy were not tested.[1]

Figures

Study flow diagram ending with the 200-patient cohort and the two repeat-imaging findings.
Figure 1. Patient-selection flow and the two reported imaging outcomes. The figure's initial registry count differs from the Results text; see Criticisms.[1]

Source: Kaiser et al., Neurological Research and Practice (2026), Fig. 1, PMCID 13651026. Reproduced unmodified under CC BY 4.0; source article.

Authors' proposed post-transfer reassessment pathway, which the caption says requires validation.
Figure 2. Authors' proposed pathway places arrival neurologic reassessment first and uses baseline CTASI ASPECTS and collateral status as modifiers. The authors explicitly state that this association-derived pathway requires validation; it is not an established triage rule.[1]

Source: Kaiser et al., Neurological Research and Practice (2026), Fig. 2, PMCID 13651026. Reproduced unmodified under CC BY 4.0; source article.

Criticisms

  • Only 19 eligibility-changing events informed the models, producing wide uncertainty for some estimates; analyses were complete-case and the design cannot establish causation or clinical utility.[1]
  • The cohort came from one stroke network and reflects 2016–2020 practice: alteplase was standard and transfer evaluation required baseline ASPECTS ≥5.[1] Applicability to other systems, newer thrombolytic practice, or current EVT selection is untested.[1]
  • Neurologic assessments were made by different trained assessors; formal NIHSS certification was not uniformly documented.[1] Single-phase CTA may underestimate collaterals, and CTASI ASPECTS is not an established standard-of-care marker.[1]
  • Internal count discrepancy: Results text states that 1,389 patients were assessed, while the linked Figure 1 image labels 1,369.[1] The subsequent 883 transfer count and 200 analyzed patients are reported in the paper; the initial count mismatch remains unresolved.[1]
  • The proposed Figure 2 pathway is derived from observational associations and is labeled for validation.[1] The study did not prospectively test thresholds, time saved, missed EVT, safety, or patient outcomes under selective imaging.[1]

Funding

Open Access funding was enabled and organized by Projekt DEAL; the authors report that no specific funding was received for this work.[1]

The paper

  • Authors. Daniel P.O. Kaiser, Julia Holzer, Daniela Schoene, Volker Puetz, and Matthias Gawlitza.[1]
  • Title. Post-transfer reassessment for endovascular treatment: factors associated with changes in EVT eligibility.[1]
  • Journal. Neurological Research and Practice. 2026;8:83.[1]
  • DOI. 10.1186/s42466-026-00539-8.
  • PMCID / PMID. PMC13651026 / 42855745.[1]
  • License. Creative Commons Attribution 4.0 International (CC BY 4.0), as stated in the article.[1]
  • Primary source. [1] — Europe PMC full-text JATS.
Deep Dive — click to expand

What this is

This is a study of how often repeat imaging after EVT transfer showed a change in eligibility-related findings and which measured features were associated with that change.[1] It is not an intervention trial of repeat imaging, and its associations cannot tell a receiving team that imaging can safely be skipped or delayed.[1]

1. Shadow Audit

The headline “one in ten” combines two different events: 5.0% had complete recanalization and 4.5% had ASPECTS 0–3 progression.[1] That is useful diagnostic-yield information, not evidence that scanning all patients helps or harms.[1] Nor does “thrombolysis associated with recanalization” mean thrombolysis identifies who has recanalized: 103 of 190 patients without recanalization had also received it.[1] The outcome was an imaging-defined eligibility change, not functional recovery, treatment benefit, or a measured delay caused by scanning.[1]

2. Inversion Engine

To overturn the authors' cautious preference for selective rather than routine repeat imaging, an externally validated strategy would need to show that it preserves timely EVT for patients who remain eligible while avoiding unnecessary tests without missing recanalization, progression, hemorrhage, or other actionable findings.[1] This cohort supplies neither an operating threshold nor sensitivity, calibration, comparative workflow effects, or patient-outcome evidence for such a rule.[1] The high OR for thrombolysis has a wide CI (1.08–46.25), and a near-significant neurologic-improvement estimate (P=0.059) is not a validated decision boundary.[1]

3. Second-Order Catalyst

The practical next step is prospective, multicenter validation of a standardized arrival examination linked to original imaging, with repeat-scan decisions governed by a prespecified and tested protocol.[1] Record door-to-puncture time, treatment decisions, missed or unnecessary procedures, safety events, and functional outcomes.[1] Until that work exists, the paper's proposed flowchart is a research hypothesis—not a bedside transfer algorithm.[1]

4. Asymmetric Leverage

Most of this selected cohort had no reported imaging change affecting eligibility, while a small minority had a finding that could matter to the EVT decision.[1] That creates a plausible efficiency question: can reassessment be targeted without delaying the much larger group still headed to treatment?[1] But transfer duration was narrowly distributed and rapidly managed, and the study did not compare workflow strategies.[1] The potential leverage is therefore a hypothesis, not an estimate of time saved or net benefit.[1]

5. Paradigm Destroyer

The useful challenge is to the assumption that eligibility is frozen at the referring hospital—not to the opposite reflex that everyone should receive repeat imaging, or that stable patients should bypass imaging.[1] A measured practice response is structured neurologic reassessment on arrival and explicit review of baseline scans, while retaining the existing validated local pathway until a selective protocol is prospectively tested.[1]

MVP — Minimum Viable Proof

A multicenter prospective study would need to validate a prespecified selection pathway and demonstrate that it reduces repeat imaging or treatment delay without increasing missed EVT, harm, or worse patient-centered outcomes.[1] This paper alone does not provide that proof.[1]

Best Combination

The most defensible synthesis is to pair the clinical examination with baseline CTASI and collateral context as candidate predictors, then test them against actual treatment decisions and patient outcomes.[1] Do not combine the associations into an informal bedside score or treat one marker as a stand-alone trigger.[1]

Overvalue Warning

Do not mistake a proposed, unvalidated pathway for an endorsed clinical rule, or interpret the absence of a transfer-duration association in a fast, selected cohort as evidence that time does not matter.[1] Also do not equate repeat-imaging eligibility changes with a demonstrated improvement in functional outcome.[1]

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