The golden hour of acute ischemic stroke

Golden Hour Intravenous Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

OBJECTIVES

The benefits of intravenous thrombolysis are time-dependent, with maximum efficacy when administered within the first "golden" hour after onset. Nevertheless, the impact of golden hour thrombolysis has not been well quantified.

METHODS

Medline, Embase, and Web of Science databases were systematically searched from inception to August 27, 2023. We included studies that reported safety and efficacy outcomes of ischemic stroke patients treated with intravenous thrombolysis in the golden hour versus later treatment window. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0-1 at 90 days. The secondary efficacy outcome was a good functional outcome (defined as modified Rankin Scale score of 0-2). The main safety outcome was symptomatic intracerebral hemorrhage.

RESULTS

Seven studies involving 78,826 patients met the selection criteria. Golden hour thrombolysis was associated with higher odds of 90-day excellent functional outcomes (OR 1.40, 95% CI 1.16-1.67) and 90-day good functional outcomes (OR 1.38, 95% CI 1.13-1.69) compared with thrombolysis outside the golden hour. The number needed to treat to benefit for golden hour thrombolysis to reduce disability by at least 1 level on the modified Rankin Scale per patient was 2.6. Rates of symptomatic intracerebral hemorrhage and mortality were similar between groups.

INTERPRETATION

Golden hour thrombolysis significantly improved acute ischemic stroke outcomes. The findings provide rationale for intensive efforts aimed at expediting thrombolytic therapy within the golden hour window following the onset of acute ischemic stroke. ANN NEUROL 2024;96:582-590.

The underlying mechanism of calcium toxicity-induced autophagic cell death and lysosomal degradation in early stage of cerebral ischemia

Cerebral ischemia is the important cause of worldwide disability and mortality, that is one of the obstruction of blood vessels supplying to the brain. In early stage, glutamate excitotoxicity and high level of intracellular calcium (Ca2+) are the major processes which can promote many downstream signaling involving in neuronal death and brain tissue damaging. Moreover, autophagy, the reusing of damaged cell organelles, is affected in early ischemia. Under ischemic conditions, autophagy plays an important role to maintain energy of the brain and its function. In the other hand, over intracellular Ca2+ accumulation triggers excessive autophagic process and lysosomal degradation leading to autophagic process impairment which finally induce neuronal death. This article reviews the association between intracellular Ca2+ and autophagic process in acute stage of ischemic stroke.

Machine Learning-Based Prediction of Stroke in Emergency Departments

Background

Stroke misdiagnosis, associated with poor outcomes, is estimated to occur in 9% of all stroke patients.

Objectives

We hypothesized that machine learning (ML) could assist in the diagnosis of ischemic stroke in emergency departments (EDs).

Design

The study was conducted and reported according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines. We performed model development and prospective temporal validation, using data from pre- and post-COVID periods; we also performed a case study on a small cohort of previously misdiagnosed stroke patients.

Methods

We used structured and unstructured electronic health records (EHRs) of 56,452 patient encounters from 13 hospitals in Pennsylvania, from September 2003 to January 2021. ML pipelines, including natural language processing, were created using pre-event clinical data and provider notes in the EDs.

Results

Using pre-event information, our model's area under the receiver operating characteristics curve (AUROC) ranged from 0.88 to 0.92 with a similar range accuracy (0.87-0.90). Using provider notes, we identified five models that reached a balanced performance in terms of AUROC, sensitivity, and specificity. Model AUROC ranged from 0.93 to 0.99. Model sensitivity and specificity reached 0.90 and 0.99, respectively. Four of the top five performing models were based on the post-COVID provider notes; however, no performance difference between models tested on pre- and post-COVID was observed.

Conclusion

This study leveraged pre-event and at-encounter level EHR for stroke prediction. The results indicate that available clinical information can be used for building EHR-based stroke prediction models and ED stroke alert systems.

Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway

BACKGROUND

In 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness, Visual loss, Speech disturbance) to detect acute ischaemic stroke (AIS) with large vessel occlusion (LVO). For patients with gaze deviation and at least one other G-FAST symptom, a primary stroke centre (PSC) may be bypassed and the patient taken directly to a comprehensive stroke centre (CSC) for rapid endovascular treatment (EVT) evaluation. The study aim was to investigate the efficacy of the G-FAST criteria for LVO patient selection and direct transfer to a CSC.

METHODS

This retrospective study included patients with code-red emergency medical communication centre (EMCC) stroke suspicion ambulance dispatch between August to December 2020. Stroke suspicion was defined as having at least one G-FAST symptom at EMS arrival. We obtained patient data from dispatches from EMCCs, EMS records and local EVT registries. Clinical features, CT images, and reperfusion treatment were recorded. The test characteristics for gaze deviation plus one other G-FAST symptom in detecting LVO were determined.

RESULTS

Among 643 patients, 59 were diagnosed with LVO at hospital arrival. In this group, seven fulfilled the G-FAST criteria for direct transport to a CSC at EMS arrival on scene, resulting in a sensitivity of 12% (95% CI 5% to 23%). The specificity was 99.66% (95% CI 98.77% to 99.96%), the positive predictive value 78%, and the negative predictive value 92%. EVT was performed in 64% (38/59) of LVO cases. Median time from PSC arrival to start of EVT at a CSC was 163 min.

CONCLUSION

The use of local G-FAST prehospital criteria by EMS personnel to identify patients with AIS with LVO is not suitable for selection of patients with LVO for direct transfer to a CSC.

Using Geographic Information Systems in health disparities research: Access to care considerations

In health disparities research, Geographic Information Systems (GIS) provide nurse researchers with powerful tools to incorporate spatial factors, such as access to care and related attributes like socioeconomic and environmental characteristics, into their studies. This article educates nurse scientists about GIS-based research benefits and considerations (focusing on access-to-care factors) and the influence of various access-to-care metrics on research outcomes. We present an overview of GIS in nursing and health disparities research, along with findings from our 2022 study examining access to care's relationship with county-level mortality rates in Tennessee, especially in areas where rural hospitals closed between 2010 and 2019. We highlight three distinct access-to-care measures (Euclidean distances and road network-based travel times based on county and census tract centroids), showcasing how different calculations impact our modeling results. Our results underscore the importance of understanding the choice of access-to-care metrics in GIS-based research to draw valid conclusions.

Associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke

To investigate the association between the Emergency Medical Service dispatcher's initial stroke triage and prehospital stroke management, primary admission to hospitals offering revascularization treatment, prehospital time delay, and rate of acute revascularization. In an observational cohort study, patients with acute ischemic stroke (AIS) in Denmark (2017-2018) were included if the emergency call to the Emergency Medical Dispatch Center (EMDC) was made within three hours after symptom onset. Among 3546 included AIS patients, the EMS dispatcher identified 74.6% (95% confidence interval (CI) 73.1-76.0) correctly as stroke. EMS dispatcher stroke recognition was associated with a higher rate of primary admission to a hospital offering revascularization treatment (85.8 versus 74.5%); producing an adjusted risk difference (RD) of 11.1% (95% CI 7.8; 14.3) and a higher rate of revascularization treatment (49.6 versus 41.6%) with an adjusted RD of 8.4% (95% CI 4.6; 12.2). We adjusted for sex, age, previous stroke or transient ischemic attack, and stroke severity. EMDC stroke recognition was associated with shorter prehospital delay. For all AIS patients, the adjusted difference was - 33.2 min (95% CI - 44.4; - 22.0). Among patients receiving acute revascularization treatment (n = 1687), the adjusted difference was -12.6 min (95% CI - 18.9; - 6.3). Stroke recognition by the EMS dispatcher was associated with a higher probability of primary admission to a hospital offering acute stroke treatment, and subsequently with a higher rate of acute revascularization treatment, and with an overall reduction in prehospital delay.

Metric based virtual simulation training for endovascular thrombectomy improves interventional neuroradiologists' simulator performance

OBJECTIVE

Metric based virtual reality simulation training may enhance the capability of interventional neuroradiologists (INR) to perform endovascular thrombectomy. As pilot for a national simulation study we examined the feasibility and utility of simulated endovascular thrombectomy procedures on a virtual reality (VR) simulator.

METHODS

Six INR and four residents participated in the thrombectomy skill training on a VR simulator (Mentice VIST 5G). Two different case-scenarios were defined as benchmark-cases, performed before and after VR simulator training. INR performing endovascular thrombectomy clinically were also asked to fill out a questionnaire analyzing their degree of expectation and general attitude towards VR simulator training.

RESULTS

All participants improved in mean total procedure time for both benchmark-cases. Experts showed significant improvements in handling errors (case 2), a reduction in contrast volume used (case 1 and 2), and fluoroscopy time (case 1 and 2). Novices showed a significant improvement in steps finished (case 2), a reduction in fluoroscopy time (case 1), and radiation used (case 1). Both, before and after having performed simulation training the participating INR had a positive attitude towards VR simulation training.

CONCLUSION

VR simulation training enhances the capability of INR to perform endovascular thrombectomy on the VR simulator. INR have generally a positive attitude towards VR simulation training. Whether the VR simulation training translates to enhanced clinical performance will be evaluated in the ongoing Norwegian national simulation study.

Building a Machine Learning-based Ambulance Dispatch Triage Model for Emergency Medical Services

Background

In charge of dispatching the ambulances, Emergency Medical Services (EMS) call center specialists often have difficulty deciding the acuity of a case given the information they can gather within a limited time. Although there are protocols to guide their decision-making, observed performance can still lack sensitivity and specificity. Machine learning models have been known to capture complex relationships that are subtle, and well-trained data models can yield accurate predictions in a split of a second.

Methods

In this study, we proposed a proof-of-concept approach to construct a machine learning model to better predict the acuity of emergency cases. We used more than 360,000 structured emergency call center records of cases received by the national emergency call center in Singapore from 2018 to 2020. Features were created using call records, and multiple machine learning models were trained.

Results

A Random Forest model achieved the best performance, reducing the over-triage rate by an absolute margin of 15% compared to the call center specialists while maintaining a similar level of under-triage rate.

Conclusions

The model has the potential to be deployed as a decision support tool for dispatchers alongside current protocols to optimize ambulance dispatch triage and the utilization of emergency ambulance resources.

High Neutrophil-Lymphocyte Ratio and Low Lymphocyte-Monocyte Ratio Combination after Thrombolysis Is a Potential Predictor of Poor Functional Outcome of Acute Ischemic Stroke

(1) Background: Ischemic stroke is one of the leading causes of death and disability. An inflammatory response is observed in multiple stages of cerebral ischemia, particularly in the acute phase. Recent publications revealed that the neutrophil−lymphocyte ratio (NLR) and lymphocyte−monocyte ratio (LMR) may be used to predict long-term prognosis in acute ischemic stroke (AIS) after thrombolysis. To test whether there is a relationship between the combination of these parameters and long-term prognosis, we analyzed the NLR−LMR combination in AIS patients treated with intravenous recombinant tissue plasminogen activator (rtPA); (2) Methods: The study included 285 adults with a diagnosis of AIS and rtPA treatment within a 4.5 h time window. Blood samples were obtained at admission and 24 h after thrombolysis to calculate pre- and post-thrombolysis NLR and LMR. Clinical data, including NIHSS was registered on admission and day 1. The long-term outcome was defined 90 days post-event by the modified Rankin Scale (mRS). Therapy-associated intracranial hemorrhage (ICH) was classified according to ECASS II. Receiver operating characteristic curve (ROC) analysis was performed to determine optimal cutoffs of NLR and LMR as predictors of therapy outcomes; (3) Results: Patients were stratified by cutoffs of 5.73 for NLR and 2.08 for LMR. The multivariate logistic regression model, including all possible confounders, displayed no significant association between NLR or LMR with 3-months functional prognosis. The combination of high NLR−low LMR vs. low NRL−high LMR as obtained 24 h after thrombolysis was found to be an independent predictor of poor 3-months functional outcome (mRS ≥ 2; OR 3.407, 95% CI 1.449 to 8.011, p = 0.005). The proportion of patients between low NLR−high LMR and high NLR−low LMR groups from admission to day 1 showed no significant change in the good outcome group. On the other hand, in the poor outcome group (mRS ≥ 2), low NLR−high LMR and high NLR−low LMR groups displayed a significant shift in patient proportions from 67% and 21% at admission (p = 0.001) to 36% and 49% at 24 h after thrombolysis (p < 0.001), respectively; (4) Conclusions: Our study demonstrated for the first time that a high NLR−low LMR combination as observed at 24 h after thrombolysis can serve as an independent predictor of 3-months poor outcome in AIS patients. This simple and readily available data may help clinicians to improve the prognostic estimation of patients and may provide guidance in selecting patients for personalized and intensified care post-thrombolysis.

Cost-Effectiveness of Mobile Stroke Unit Care in Norway

BACKGROUND:

Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).

METHODS:

We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.

RESULTS:

MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.

CONCLUSIONS:

MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.

Application time and persistence of transcranial direct current stimulation (tDCS) against neuronal death resulting from transient cerebral ischemia

BACKGROUND

Transcranial direct current stimulation (tDCS) has been studied as a tool to stimulate the functional recovery of neurons after stroke. Although this device has recently begun to be utilized for providing neuroprotection in stroke, research on its application conditions is lacking. This study aimed to examine the effects of various tDCS application conditions on cerebral ischemia. Ischemia was induced for 5 min in a gerbil model. The application of tDCS comprised a 20 min stimulation-20 min rest-20 min stimulation protocol, which was implemented simultaneously with the induction of cerebral ischemia. Application time of the tDCS effect on ischemia was confirmed by sampling brain tissues after stimulation using 0.2 mA tDCS at 0, 5, 10 and 60 min after ischemia.

RESULTS

Persistence of the tDCS effect on ischemia was confirmed by sampling brain tissues 5, 7, and 10 days post stimulation, with 0.2 mA tDCS after ischemia. Furthermore, the tissues were stained with cresyl violet and Fluoro-Jade C so as to determine the reduction in neuronal death under all application conditions.

CONCLUSIONS

The application of tDCS can be used as a useful intervention for acute phase stroke due to its sustained neuroprotective effect.

Role of imaging in early diagnosis of acute ischemic stroke: a literature review

Stroke is a serious health condition that is responsible for more than 5% of total deaths. Near 20% of patients experiencing stroke die every year, resulting in the stroke being at the top of the list of preventable causes of death. Once an acute stroke is suspected, a golden hour of less than an hour is available to prevent the undesirable consequences. Since neuroimaging is mandatory in the diagnosis of stroke, the proper use of neuroimaging could help saving time and planning the right treatment for the patient. Some of the available imaging methods help us with rapid results, while others benefit us from a more accurate diagnosis. Hereby, we aim to provide a clinical review of the advantages and disadvantages of different available neuroimaging methods in approaching acute stroke to help clinicians choose the best method according to the settings.

Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke

Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.

Prevalence of stroke survival in rural communities living in northern Peru

BACKGROUND AND PURPOSE

Stroke is the leading cause of neurological impairment in the South American Andean region. However, the epidemiology of stroke in the region has been poorly characterized.

METHODS

We conducted a staged three-phase population-based study applying a validated eight-question neurological survey in 80 rural villages in Tumbes, northern Peru, then confirmed presence or absence of stroke through a neurologist's examination to estimate the prevalence of stroke.

RESULTS

Our survey covered 90% of the population (22,278/24,854 individuals, mean age 30±21.28, 48.45% females), and prevalence of stroke was 7.05/1,000 inhabitants. After direct standardization to WHO's world standard population, adjusted prevalence of stroke was 6.94/1,000 inhabitants. Participants aged ≥85 years had higher stroke prevalence (>50/1000 inhabitants) compared to other stratified ages, and some unusual cases of stroke were found among individuals aged 25-34 years. The lowest age reported for a first stroke event was 16.8 years. High blood pressure (aPR 4.2 [2.7-6.4], p>0.001), and sedentary lifestyle (aPR 1.6 [1.0-2.6], p = 0.045) were more prevalent in people with stroke.

CONCLUSIONS

The age-standardized prevalence of stroke in this rural coastal Peruvian population was slightly higher than previously reported in studies from surrounding rural South American settings, but lower than in rural African and Asian regions. The death rate from stroke was much higher than in industrialized and middle-income countries.

Role of Telemedicine in Prehospital Stroke Care

PURPOSE OF REVIEW

To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions.

RECENT FINDINGS

A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.

Blood Pressure Variability during Angiography in Patients with Ischemic Stroke and Intracranial Artery Stenosis

Our aim was to investigate factors predicting blood pressure (BP) variability during diagnostic cerebral angiography and associations between BP variability and clinical outcomes in patients with acute and subacute ischemic stroke and intracranial artery stenosis. 114 patients with ischemic stroke and intracranial artery stenosis (stenosis rate >50%) were recruited. Patients who underwent cerebral angiography within 3 days and 3-14 days of disease onset are referred to be Group A and Group S, respectively. BP variability in Group A was defined as the coefficient of variance (CV) of BP. Univariate and multivariate regression analyses were used to identify predictors of CV of BP and associations between CV of BP and clinical outcomes at discharge. In Group A patients, advanced age was associated with increased CV of SBP and diastolic blood pressure (DBP), and antihypertensive use was associated with lower CV of SBP. Male was associated with lower CV of DBP. In Group S, higher CV of SBP was associated with hypertension and antihypertensive use. Males had lower CV of SBP than females. The calcium channel blocker was associated with lower CV of DBP. Higher scores of the Stroke Scale at admission were significantly associated with poor clinical outcomes for both groups, while BP variability was not. Factors associated with BP variability are significantly different between stroke patients undergoing angiography within 3 days vs. 3-14 days after disease onset. BP variability is not significantly associated with clinical outcomes at discharge.

Using artificial intelligence for improving stroke diagnosis in emergency departments: a practical framework

Stroke is the fifth leading cause of death in the United States and a major cause of severe disability worldwide. Yet, recognizing the signs of stroke in an acute setting is still challenging and leads to loss of opportunity to intervene, given the narrow therapeutic window. A decision support system using artificial intelligence (AI) and clinical data from electronic health records combined with patients' presenting symptoms can be designed to support emergency department providers in stroke diagnosis and subsequently reduce the treatment delay. In this article, we present a practical framework to develop a decision support system using AI by reflecting on the various stages, which could eventually improve patient care and outcome. We also discuss the technical, operational, and ethical challenges of the process.

[Analysis of comorbidities in hospitalized patients for ischemic stroke and their effects on lethality]

OBJECTIVES

The aim of the study consists of analyzing the comorbidities of acute ischemic stroke and those influencing its hospital lethality.

METHODS

We considered patients from Wallonia aged 25 years or more and admitted to a Belgian hospital for an acute ischemic stroke in 2013 and 2014. The analyzed medico-administrative data are taken from the Minimum Hospital Summary. A factorial correspondence analysis (FCA) was used to demonstrate the comorbidities profiles. A logistic regression was used to analyse the comorbidities influencing hospital lethality by ischemic stroke.

RESULTS

The stroke risk factors vary according to the age. Cardiac problems are more common in older people aged 85 years or more. High blood pressure, hypercholesterolemia and diabetes are more present between 65- and 84-year-olds. Overweight is more present between 55 and 74-year-olds. People who are addicted to alcohol or tobacco are often 65 years or younger. The logistic regression showed that age and heart problems are the risk factors that increase lethality. However there is a lethality diminution in the presence of high blood pressure, hypercholesterolemia, overweight and addiction to alcohol or tobacco.

CONCLUSION

This study demonstrates that medico-administrative databases and factorial statistical methods are perfectly adapted to confirm the ischemic stroke risk factors. This type of study will allow to target with more precision the secondary and tertiary prevention actions of stroke.

Assessment of post discharge medication prescription among Lebanese patients with cerebral infarction: Results of a cross-sectional study

OBJECTIVES

The study objective was to investigate the degree of physician adherence with the international guidelines for post-stroke discharge medications among Lebanese hospitals.

PATIENT AND METHODS

This retrospective observational study was conducted in three Lebanese hospitals between January 2016 and December 2017.

RESULTS

Out of 200 patients with stroke, 64.7 % were males. The difference of systolic blood pressure from baseline, 2 h, and after 24 h showed significant decrease by mean value 25.18 ± 33.45 (P < 0.001), and 6.44 ± 22.11 (P = 0.019) respectively. Also diastolic blood pressure showed significant decrease between baseline and after 24 h by a mean value 12.17 ± 13.63 (P value <0.001). Concerning post discharge medications adherence, antithrombotic drugs showed the highest percentage (73 %) followed by antihypertensive and lipid lowering agents by comparable results (47.5 % and 40.7 % respectively). The physician adherence for the three medications together showed (30.4 %).

CONCLUSION

Secondary prevention for critical diseases such as stroke appears to be inadequate in the study area.

Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre

Background

In eligible patients with acute ischaemic stroke, rapid revascularisation is crucial for good outcome. At our treatment centre, we had achieved and sustained a median door-to-needle time of under 30 min. We hypothesised that further improvement could be achieved through implementing a revised treatment protocol and in situ simulation-based team training sessions. This report describes a quality improvement project aiming to reduce door-to-needle times in stroke thrombolysis.

Methods

All members of the acute stroke treatment team were surveyed to tailor the interventions to local conditions. Through a review of responses and available literature, the improvement team suggested changes to streamline the protocol and designed in situ simulation-based team training sessions. Implementation of interventions started in February 2017. We completed 14 simulation sessions from February to June 2017 and an additional 12 sessions from November 2017 to March 2018. Applying Kirkpatrick’s four-level training evaluation model, participant reactions, clinical behaviour and patient outcomes were measured. Statistical process control charts were used to demonstrate changes in treatment times and patient outcomes.

Results

A total of 650 consecutive patients, including a 3-year baseline, treated with intravenous thrombolysis were assessed. Median door to needle times were significantly reduced from 27 to 13 min and remained consistent after 13 months. Risk-adjusted cumulative sum charts indicate a reduced proportion of patients deceased or bedridden after 90 days. There was no significant change in balancing measures (stroke mimics, fatal intracranial haemorrhage and prehospital times).

Conclusions

Implementing a revised treatment protocol in combination with in situ simulation-based team training sessions for stroke thrombolysis was followed by a considerable reduction in door-to-needle times and improved patient outcomes. Additional work is needed to assess sustainability and generalisability of the interventions.

Multimode Computed-Tomography-Guided Thrombolysis under a Prolonged Time Window in Acute Ischemic Stroke Patients with Atrial Fibrillation

Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.