Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Door to Needle Count Down: A 3-Years Experience in an Egyptian University Stroke Center

BACKGROUND

The purpose of this study is to share our experience in changing hospital strategies to achieve rapid thrombolysis in acute ischemic stroke (AIS) patients in 2 university stroke centers. Rapid reperfusion by shortening door to needle time (DTN) reduces morbidity and mortality for patients with AIS. Our aim is to evaluate the effect of applying certain logistic strategies to reduce DTN for thrombolysis and its impact on clinical outcome.

METHODS

In this retrospective registry-based observational study from the SITS-ISTR Dataset, we studied AIS patients admitted to 2 stroke centers in Ain Shams University over 3 successive years from 2016 till 2018. We analyzed change of DTN and outcome at 3 months by modified Rankin scale over these 3 years.

RESULTS

By the end of the 3 year period there was a 6.1% increase in number of patients receiving thrombolysis. There was a significant decrease of median DTN by 41%, and increase in percentage of patients receiving recombinant tissue plasminogen activator within a shorter DTN. Also, the number of patients with a favorable outcome (modified Rankin scale≤2) increased by 23.3%. There was insignificant difference regarding mortality rate.

CONCLUSION

Applying a goal-directed corrective strategy to improve quality of service can, in a short time, reduce DTN and improve patient outcome.

Reperfusion Therapies for Children With Arterial Ischemic Stroke

ABSTRACT

Modern hyperacute reperfusion therapies including intravenous thrombolysis and mechanical thrombectomy have transformed the management of arterial ischemic stroke (AIS) in adults. Multiple randomized clinical trials have demonstrated that these therapies enable remarkable improvements in clinical outcome for properly selected patients with AIS. Because pediatric patients were excluded from predicate clinical trials, there is a conspicuous lack of data to guide selection of therapies and inform age-adjusted and pathology-oriented treatment modifications for children. Specifically, technical guidance concerning treatment eligibility, drug dosing, and device implementation is lacking. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with therapeutic decision making.

Temporal sustainability of guideline based door-to-needle times for intravenous thrombolysis for acute ischemic stroke

BACKGROUND

Door to needle (DTN) time provides valuable insight into stroke care workflow and is a performance indicator of an acute stroke unit. The aim of the current study was to ascertain whether a door to needle time of less than 60 min can be achieved for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) and maintained long term in a comprehensive stroke unit.

METHODS

Patients with AIS treated with IVT in the stroke unit formed the study group. Demographic and clinical characteristics including door to imaging (DTI) time, DTN time, and 3 month functional outcome were abstracted. Pairwise comparison was done of yearly median DTI and DTN times with Bonferroni correction.

RESULTS

Over a period of 6 years a total of 196 patients with mean age of 61.5 ± 13.1 years and median (IQR) NIHSS 11 (8-16) underwent IVT. The median DTI time and DTN time over the study period was 15 (12-21) minutes and 40 (30-50) minutes respectively. A total of 90.1%, 69.4% and 29.1% patients received IVT within 60 min, 45 min and 30 min respectively. On pairwise comparison of the median yearly DTN Year 2016 and 2017 were lower compared to most of the earlier years (p < 0.0001). Good functional outcome (mRS ≤ 2) was noted in 68.7% patients at 3 months follow-up.

CONCLUSION

It is possible to sustainably reduce DTN time for IVT in AIS to well below the current 60 min benchmark with hospital system training and teamwork.