An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis

OBJECTIVES

To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment.

DESIGN

Prospective study.

SETTING

A university teaching hospital in Hong Kong.

PATIENTS

Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009.

MAIN OUTCOME MEASURES

Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality.

RESULTS

During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient.

CONCLUSION

A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.

Wingspan experience at Beijing Tiantan Hospital: new insights into the mechanisms of procedural complication from viewing intraoperative transient ischemic attacks during awake stenting for vertebrobasilar stenosis

BACKGROUND AND AIM

Intracranial vertebrobasilar artery (VBA) stenosis portends a stroke and death rate of 8.5-22.8% annually despite medical therapy. Stenting has emerged as a treatment option but also carries substantial risk. Awake stenting under local anesthesia to minimize major procedural complication was investigated.

METHODS

Between January 2007 and December 2008, 43 of 46 consecutive patients with severe symptomatic intracranial VBA stenosis underwent elective angioplasty assisted with self-expanding Wingspan stent under local anesthesia at our institute. All data were collected prospectively.

RESULTS

All 43 patients tolerated the stenting procedure under local anesthesia well. Forty-two patients (97.7%) were stented successfully. Within 30 days, there were three periprocedural strokes, including thromboembolic infarct, pontine perforator infarct and intracranial hemorrhage, without fatality. In addition, five patients had intraoperative brainstem transient ischemic attacks (TIAs) seconds after the deployment of the stent delivery system across the tortuous VBA. The symptoms and signs included impaired consciousness (n=5), dysarthria (n=3), convulsion (n=2), conjugate horizontal gaze palsy (n=2), nystagmus (n=2) and pinpoint pupils (n=1). There was angiographic evidence of VBA straightening without thromboembolism. The TIAs resolved within minutes of prompt removal of the delivery catheter.

CONCLUSIONS

VBA stenting under local anesthesia is feasible with a 7% periprocedural stroke risk. Awake stenting allows timely detection of intraoperative TIAs. The mechanism of intraoperative TIA appears to be stent delivery system induced VBA straightening and distortion of its vascular tree. A devastating stroke may ensue if the TIA is not detected and distortion of VBA perforators is not reversed promptly.

Long-term outcome of tandem stenting for stenoses of the intracranial vertebrobasilar artery and vertebral ostium

BACKGROUND AND PURPOSE

Patients with symptomatic atherosclerotic stenosis of the intracranial vertebrobasilar artery (VBA) have a poor prognosis, and those with coexistent intracranial and extracranial stenoses have worse outcomes despite medical therapy. Our aim was to study the long-term outcome of patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and the vertebral artery ostium (VAO) after elective stent placement.

MATERIALS AND METHODS

Ten consecutive patients (mean age, 65.3 years) with this condition underwent elective stent placement at our institution between September 2001 and December 2007. Technical success was defined as stent placement of both VAO and intracranial VBA stenoses with complete stent coverage of the lesions, residual stenosis of < or = 30%, and good antegrade blood flow. The study end point was a composite of any stroke or death within 30 days and ischemic stroke in the VBA territory after 30 days.

RESULTS

Technical success was obtained in 9 of 10 patients without any stroke or death within 30 days. During a median follow-up duration of 32 months, 1 patient had a fatal ischemic stroke in the VBA territory at 4 months, and the other 9 patients were free from stroke recurrence. Thus, the annual stroke rate in VBA territory (including any stroke or death within 30 days) was 3.8%.

CONCLUSIONS

This pilot study shows that elective stent placement for patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and VAO has an acceptable long-term outcome and may be considered as an alternative to medical therapy.