What is the door-to-device time goal for direct arriving patients with acute ischemic stroke

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Volume 29, Issue 1, January 2020, 104477

Stroke is a leading cause of death and disability in the United States.1 For eligible patients, early administration of intravenous tissue plasminogen activator (tPA) improves outcome and reduces long term disability.2, 3, 4 This intervention is time sensitive, with earlier administration of tPA resulting in the greatest patient benefit.5, 6, 7, 8 National guidelines recommend establishing and monitoring target time goals for emergency department (ED) door-to-needle (DTN) time,4 and national quality improvement programs have set the primary target for DTN at 60 minute, and secondary targets at 45 minute and 30 minutes.9,10 Achieving these goals require patient care flow optimization and continuous quality improvement.11,12

Distinguishing ischemic from hemorrhagic stroke is a mandatory initial step in evaluating patients for thrombolysis eligibility. Therefore, the American Heart Association/American Stroke Association's (AHA/ASA) Target: Stroke initiative included rapid acquisition of brain imaging in its initial 10 best practice strategies to reduce DTN,13 with a national goal for door-to-imaging (DTI) of 25 minutes.4,9 Several single-center case series reported that implementation of a policy to route emergency medical services (EMS)-transported stroke patients directly to the computed tomography (CT) scanner prior to evaluation in an ED bed resulted in accelerated DTI and DTN times.14, 15, 16 On the basis of these findings, the AHA/American Stroke Association's Target: stroke national quality improvement program added direct-to-CT/MRI as an 11th recommended strategy in 2014.13

However, single-center, before-after studies of the effect of direct-to-CT routing on DTI and DTN times may not be generalizable and are subject to confounding by general secular trends toward improvements in timeliness of other aspects of care occurring in the study time frames. Accordingly, we undertook an analysis of DTN and DTI times assessing direct-to-CT versus ED-bed first routing policies using comparator hospitals in the same time period in a large regionalized stroke system.

This was a retrospective analysis of prospectively acquired registry data from the Los Angeles (LA) County EMS system. The study was reviewed and approved by the Lundquist Institute at Harbor-UCLA institutional review board.

LA County is a large metropolis, comprising 88 cities spanning over 4000 square miles with a population of approximately 10.2 million. LA County EMS Agency operates a regional stroke system of care. During the time period of this study, patients with acute stroke who

During the study period, EMS transported 6315 patients for suspected stroke, among whom 789 patients (13%) were treated with IV tPA. The thrombolytic-treated patients included 171 (22%) treated at hospitals with direct-to-CT routing policies and 618 (78%) treated at hospitals with ED-bed routing. Patient characteristics are shown in Table 2. Overall, median age was 73, 47% were female, race ethnicity was diverse, including 24% Hispanic ethnicity, 14% Asian, and 10% Black, and median NIH stroke

In this large regional stroke system, while we did observe a reduction in DTI times at EMS-designated ASCs using direct-to-CT routing protocols compared to centers using traditional ED-bed first routing, we did not find a reduction in DTN times. DTN times were actually marginally increased at ASCs with direct-to-CT routing protocols in the subset of patients without a positive prehospital stroke screen. Further, the reduction in DTI time appeared to be lessened during on-hours.

Our findings

In this regional stroke system, hospitals with protocols for routing EMS-transported stroke patients directly to CT did not have reduced DTN compared to hospitals without such protocols.

This work was completed without external funding. LP and NS have no disclosures. BS, NB, and MGH have no personal disclosures. Their institutions are affiliated with the University of California, The University of California Regents have patent rights in retrieval devices for stroke. JLS' institution is owned by the University of California. The University of California has patent rights in retrieval devices for stroke. He has served as an unpaid site investigator in multicenter trials

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GC Fonarow et al.

Objective: Gastrodin, a glucoside of gastrodigenin, inhibits cerebral oxidant stress and apoptosis in multiple central nervous system injury, but its effect in intracerebral hemorrhage (ICH) remains unclear. This study investigated the effect of gastrodin on neuronal apoptosis and neurological deficits in rat ICH model. Methods: In vitro experiments were performed using hematoma lysate-induced cell damage model in primary cortical neurons. Rat ICH model was produced by a caudatum injection of collagenase. Gastrodin was intraperitoneal injected after 2 hours following ICH. Cell viability, brain water content, neurological score, western blot, and immunofluorescence experiments were performed. Results: Gastrodin significantly decreased hematoma lysate-induced reduction of cell viability and cell apoptosis in primary cortical neurons. Gastrodin significantly improved brain edema and neurological deficits post-ICH. Moreover, gastrodin administration significantly reduced levels of ROS, 8-OHDG, 3-Nitrotyrosine and MDA, while increased GSH-Px and SOD activity, and stimulated the upregulation of Keap1, Nrf2, and HO-1 signaling at 72 hours post-ICH. Furthermore, gastrodin significantly increased Bcl-2 expression, while reduced level of Bax, active caspase-3 and active caspase-9, also reduced the number of active caspase-3 or TUNEL positive neurons at 72 hours post-ICH. Conclusion: These results suggest that gastrodin is neuroprotective after ICH and the mechanism may be associated with the inhibition of oxidative stress and neuronal apoptosis.
Complete spontaneous thrombosis of intracranial aneurysms is uncommon. Although this type of thrombosis is largely asymptomatic, in rare cases it can be accompanied by parent artery occlusion and ischemic stroke. There are limited reports of complete thrombosis of an unruptured aneurysm of the internal carotid artery and middle cerebral artery. Furthermore, there are no reports of occlusion of the vertebral artery caused by thrombosis of an aneurysm. The mechanisms of spontaneous thrombosis are not established. However, aneurysm morphology, arteriosclerosis, and stagnation of aneurysm flow have been suggested. Herein, we present a novel case of Wallenberg's syndrome caused by a fusiform aneurysm in which complete thrombosis of the proximal vertebral artery occurred. We discuss the mechanisms of thrombosis caused by an unruptured aneurysm, which may be useful for managing such patients who present with transient ischemic attacks.
Impairment of endothelial function is associated with atherosclerosis and atrial fibrillation, and could underlie several types of ischemic stroke. Embolic stroke of undetermined source (ESUS) recently attracted much attention as the major cause of cryptogenic stroke. This study aimed to clarify the endothelial function of patients with ESUS.
Between 2015 September and July 2017 July, we used flow-mediated vasodilation (FMD) test to evaluate vascular endothelial function in 182 patients with any vascular risk factors or a history of cerebrovascular events. The subject group was classified into the No Stroke group and 5 stroke subtype groups, large artery atherosclerosis (LAA), cardiogenic embolism (CE), small vessel disease (SVD), ESUS, and others (Other). Endothelial function was expressed as percentage increase in brachial vessel diameter (%FMD) after the interruption of blood flow with mechanical compression for 5 minutes. Mean FMD in the No stroke, LAA, CE, SVD, ESUS and Other groups were 7.03 ± 2.14%, 5.02 ± 2.75%, 4.97 ± 1.62%, 5.19 ± 2.67%, 3.55 ± 1.42%, and 6.55 ± 3.50%, respectively. After the adjustment for confounding factors, FMD was significantly lower in the ESUS group than in the No stroke, SVD, and Other groups. FMD tended to be lower in the ESUS group than in the LAA and CE groups, but the difference was not significant.
Endothelial function was impaired in patients with ESUS and may underlie its pathophysiology.
Here, we report a case involving a 67-year-old Japanese woman with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) associated with a novel in-frame complex rearrangement in the NOTCH3 gene. The patient had gradually developed cognitive impairment since the occurrence of an ischemic stroke at the age of 53 years. Her mother had a history of stroke and dementia. Fluid-attenuated inversion recovery magnetic resonance imaging of the brain showed hyperintense lesions in the bilateral temporal poles, external capsules, and periventricular white matter accompanied by multiple cerebral microbleeds on T2*-weighted gradient-echo imaging. A novel in-frame mutation (c.598_610delinsAGAACCC) resulting in the loss of Cys201 in the fifth epidermal growth factor-like repeat of NOTCH3 was identified; this led to a diagnosis of CADASIL. In summary, we report a novel pathogenic mutation (NOTCH3 c.598_610delinsAGAACCC; p.Pro200_Ser204delinsArgThrPro) associated with CADASIL. Further investigations should elucidate the genotype-phenotype correlations in patients with this in-frame complex rearrangement.
The aim of this study was to investigate the value of extracranial carotid artery calcium score in predicting severity of carotid arterial stenosis.
200 patients who had indication of contrast neck multi detector computed tomography were included. Calcium volume score of each calcified plaque (density more than 130 HU) was determined by multiplying area of calcified plaque in slice increment and presented as cubic centimeter (cc). Calcium score of each side (right or left) and each patient were determined. Severity of carotid stenosis in axial images was estimated and categorized. Statistical analysis was performed.
87 cases were female with mean age of 58.90 ± 10.67 and 113 cases were male with mean age of 59.61 ± 11.89 years old. The mean of volume score for all evaluated 800 vessels was .079 ± .046 cc. There was no significant difference between calcium score of right and left side (P value = .16). The mean “patient score” was .080 ± .049 cc (range: 0-.15 cc).Nine patients had volume score of 0 and all of them had no evidence of luminal stenosis. Significant increase in severity of stenosis was seen with increase in “patient score”.(P value < .001, r = .875).According to receiver operating characteristic analysis, “patient score” of .09 cc with sensitivity of 97% and “patient score” of .12 cc with sensitivity of 95% can predict 50% and 70% stenosis, respectively.
Promising role of calcium score for predicting severity of carotid stenosis could be considered.
Predicting outcome after stroke is a major goal and research field. The Embolic Stroke of Undetermined Source (ESUS) is a recently introduced clinical construct, and the prediction of outcome in this population has to be further explored. The aim of the study was to evaluate the prognostic validity and accuracy of the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) score in patients with ESUS.
Consecutive patients hospitalized for acute ischemic stroke who met the ESUS diagnostic criteria were identified and the ASTRAL scores estimated. The study endpoint was the 3-month unfavorable outcome (modified Rankin Scale>2). Predictive performance was investigated through logistic regression analysis and discrimination and calibration tests.
Among 202 patients with ESUS, 67 (33.2%) had unfavourable 3-month outcome. The ASTRAL score was an independent predictor of poor outcome [adjOR = 1.44, 95% confidence interval (CI) 1.30-1.60, P < .001], showed good discriminatory power (area under the receiver operating characteristic curve .913, 95% CI .871-.956) and was well calibrated (Hosmer-Lemeshow test P = .496).
The ASTRAL score was an independent predictor of 3-month functional outcome and showed high predictive accuracy in patients with ESUS.