Abstract 3345: Does Acute Stroke Critical Pathway For Recanalization Therapy In Acute Ischemic Stroke Improve Short-term Clinical Outcome?

Abstract

Background & Objectives: The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent. However, in-hospital time delay is the most serious obstacle to achieve a goal for timely administration of intravenous tPA. Previous studies have been reported that critical pathway (CP) for acute stroke would reduce door-to-needle time, but there are few studies about the clinical efficiency. We aimed to elucidate the roll of CP for improving clinical outcomes among patients who underwent thrombolytic therapy. Method: Acute stroke CP has been implemented in our hospital since November 2010 for the purpose of reducing in-hospital delay, and applicated to the patients who were presented with focal neurologic signs within 24 hours after onset. To evaluate effectiveness of CP, we predefined time indicators as follows; arrival to consultation time by neurologist (door-to-doctor) time, arrival to tPA administration (door-to-needle) time, and arrival to intra-arterial thrombolysis (door-to-IA) time. We compared the performance of time indicators during 6 months with that of before implementation for the same months. The difference of NIH stroke scale (NIHSS) between administration and discharge was selected for comparing short-term clinical outcome between two groups. Results: A consecutive series of 282 patients with acute ischemic stroke were collected during the study period. Among them, 125 patients were assigned to ‘before CP ’ group and 157 to ‘after CP’ group. Median of Door-to-doctor time was significantly reduced after implementation of CP; 45 min (IQR, 25 to 69) vs. 17 (12 to 27) (P<0.001). Median of door-to-needle time was also significantly reduced; 58 (49 to 99) vs. 47 (40 to 59) (P=0.003). However, median of door-to-IA time was failed to reduce; 2.0 h (1.4 to 3.1) vs. 1.9 (1.6 to 2.2) (P = 0.445). The number of patients who were treated with thrombolytic therapy slightly increased from 24.8% (31/125) to 25.4% (40/157) and especially, rate of intra-arterial thrombolytic therapy significantly increase from 8.8%(11/125) to 15.2%(24/157). The analyses about the difference of clinical outcome between two groups by generalized estimating equation (GEE) showed that there was no significant improvement (P = 0.09) in terms of short-term clinical outcome which was assessed by initial and discharge NIHSS. Conclusions: Our study suggests that the acute stroke CP might be effective in reducing door-to-doctor and door-to-needle time although it could not lead to improvement of clinical outcome. The study about relationship between CP and long-term outcome should be needed for the future direction.