Needle Time Research Articles

Secondary prevention of patients with ischaemic stroke after recanalization treatment

Abstract We performed a retrospective analysis of 100 patients with ischaemic stroke. All patients underwent intravenous thrombolysis in the acute care setting (avg. 2.8 hours, max 4.5 hours) and 10 of them also underwent mechanical thrombectomy. For 20% of the patients, the stroke was fatal. Door to needle time was 38.46 minutes. Although changes in antithrombotic treatment were introduced due to strokes, there was no significant difference in National Institute of Health Stroke Scale scores between the patients who were on antithrombotic treatment and those who were on no antithrombotic treatment.

Tenecteplase for Thrombolysis in Acute Ischemic Stroke and Its Outcome—An Indian Experience

Background: Stroke has been a growing concern with increasing morbidity and mortality worldwide. Tenecteplase has been approved in India as a newer thrombolytic, in acute ischemic stroke, since 2016. Very few studies have been reported to know the efficacy of Tenecteplase in AIS compared to alteplase. Aim: This study was done to understand the efficacy and related complications of Tenecteplase in AIS. Methods: In this prospective study, we took 112 people with AIS who received Tenecteplase, admitted between August 2018 and August 2020. After obtaining ethical approval, we tabulated patients’ data and did the statistical analysis using an unpaired t test, Analysis of Variance, and chi-square test. A P value of <.05 using a 2-tailed test was considered significant for all statistical analyses. Results: Out of 112 patients, 67.9% were male and 32.1% were female, with a mean age of 60.7 years. We classified stroke by using the TOAST classification. About 62.5% are classified as large atherosclerotic type, 14.3% cardioembolic, and 17.0% lacunar strokes. A total of 82.1% had a middle cerebral artery region stroke. The mean door to needle time was 76.7 min with a standard deviation of 33.3. The primary outcome was met in 47.3%, and the secondary result was achieved in 59.8%. Intracerebral hematoma was the most commonly observed complication. Mortality accounted for 9.8% of the total population. Conclusions: Tenecteplase is the newer thrombolytic agent with good efficacy. More studies are needed globally to understand regional differences and effectiveness.

The Effect of the Door to Needle Time of Streptokinase Administration on the Left Ventricular Function and Thrombolysis in Myocardial Infarction (TIMI) Flow Grade in Patients With Anterior Myocardial Infarction: A Single-Center, Prospective Follow-Up stud

Early administration of thrombolytic agents is the standard treatment and crucial for the outcome for patients presenting with acute myocardial infarction (MI). This study was conducted to evaluate the door to needle time of streptokinase administration and the left ventricular function in patients with anterior MI. This study was a prospective, single-center study on participants with anterior MI who were received streptokinase and non-streptokinase groups. After administration of streptokinase, QTc was measured in hyper-acute, acute, and recent phases of anterior MI in the case group and compared with acute and recent phases in the control group. The left ventricular function in 5 and 42 days after emergency department arrival was measured and compared in two groups. The data were analyzed by descriptive statistics method and variance analysis in the SPSS software, version 22. The level of significance was considered to be 0.05. Among 87 participants (45 streptokinases, 42 non-streptokinase), there was a significant relationship between the door to needle time in patients who received streptokinase in 1 hour (P=0.000), 3 hours (P=0.007), and 6 hours (P=0.016) after onset the chest pain and an ejection fraction of the patients in 5 days after hospitalization. Also, there was a significant relationship between ejection fraction in 5 days (P=0.000) and 42 days (P=0.000) of administration streptokinase and door to needle time. Reduction of the door to needle time after anterior MI has significant effects on QTc and incidence of threatening arrhythmia.

The Timing of Stroke Care Processes and Development of Stroke Associated Pneumonia: A National Registry Cohort Study.

IntroductionTimely stroke care can result in significant improvements in stroke recovery. However, little is known about how stroke care processes relate to complications such as the development of stroke associated pneumonia (SAP). Here we investigated associations between stroke care processes, their timing and development of SAP.MethodsWe obtained patient-level data from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1st April 2013 and 31st December 2018. SAP was identified if new antibiotic initiation for pneumonia occurred within the first 7 days of admission. Time to key stroke care processes in the pre-hospital, hyperacute and acute phase were investigated. A mixed effects logistic regression model estimated the association between SAP [Odds ratios (OR) with 95% CI] and each process of care after controlling for pre-determined confounders such as age, stroke severity and comorbidities.ResultsSAP was identified in 8.5% of 413,133 patients in 169 stroke units. A long time to arrival at a stroke unit after symptom onset or time last seen well [OR (95% CI) = 1.29 (1.23–1.35)], from admission to assessment by a stroke specialist [1.10 (1.06–1.14)] and from admission to assessment by a physiotherapist [1.16 (1.12–1.21)] were all independently associated with SAP. Short door to needle times were associated with lower odds of SAP [0.90 (0.83–0.97)].ConclusionTimes from stroke onset and admission to certain key stroke care processes were associated with SAP. Understanding how timing of these care processes relate to SAP may enable development of preventive interventions to reduce antibiotic use and improve clinical outcomes.

Grace Under Pressure: Resiliency of Quality Monitoring of Stroke Care During the Covid-19 Pandemic in Mexico City.

Stroke is one of the leading causes of death and disability among adults worldwide. The World Health Organization (WHO) officially declared a COVID-19 pandemic on March 11, 2020. The first case in Mexico was confirmed in February 2020, subsequently becoming one of the countries most affected by the pandemic. In 2020, The National Institute of Neurology of Mexico started a Quality assurance program for stroke care, consisting of registering, monitoring and feedback of stroke quality measures through the RES-Q platform. We aim to describe changes in the demand for stroke healthcare assistance at the National Institute of Neurology and Neurosurgery during the pandemic and the behavior of stroke quality metrics during the prepandemic and the pandemic periods. For this study, we analyzed data for acute stroke patients registered in the RES-Q platform, in the prepandemic (November 2019 to February 2020) and pandemic (March-December 2020) periods in two groups, one prior to the pandemic. During the pandemic, there was an increase in the total number of assessed acute stroke patients at our hospital, from 474 to 574. The average time from the onset of symptoms to hospital arrival (Onset to Door Time—OTD) for all stroke patients (thrombolyzed and non-thrombolyzed) increased from 9 h (542 min) to 10.3 h (618.3 min) in the pandemic group. A total of 135 acute stroke patients were enrolled in this registry. We found the following results: Patients in both groups were studied with non-contrast computed tomography (NNCT), computed tomography angiography (CTA), magnetic resonance angiography (MRA), digital subtraction angiography (DSA) or more frequently in the pandemic period (early carotid imaging, Holter monitoring) as needed. Treatment for secondary prevention (antihypertensives, antiplatelets, statins) did not differ. Frequency of performing and documenting the performance of NIHSS scale at arrival and early dysphagia test improved. There was an increase in alteplase use from 21 to 42% (p = 0.03). There was a decrease in door to needle time (46 vs. 39 min p = 0.30). After the implementation of a stroke care protocol and quality monitoring system, acute stroke treatment in our institution has gradually improved, a process that was not thwarted during the COVID-19 pandemic.

The Effect of the Door to Needle Time of Streptokinase Administration on the QTc Interval and the Incidence of Life-Threatening Arrhythmia in Patients With Anterior Myocardial Infarction

Early administration of thrombolytic agents is standard for patients presenting with acute myocardial infarction (MI). Also, prolonged QT intervals indicate a higher risk for sudden death in patients with MI. This study was conducted to evaluate the door to needle time of streptokinase administration and the incidence of life-threatening arrhythmia in patients with anterior MI. This study was a prospective, single-center study on participants with anterior MI, who were divided into streptokinase and non-streptokinase groups. After administration of streptokinase, QTc was measured in hyper-acute, acute, and recent phases of anterior MI in the group and compared with acute and recent phases in the non-streptokinase group. The incidence of life-threatening arrhythmia was measured and compared in two groups. The data were analyzed by descriptive statistics method and variance analysis in the SPSS software, version 22. The level of significance was considered to be 0.05. Among 87 participants, there was a significant relationship between the door to needle time of 30 minutes and QTc interval in the hyperacute phase (P=0.005). Also, QTc in the streptokinase group was significantly lower than the non-streptokinase group in the acute phase (P=0.003 vs. P=0.205) and recent phase (P=0.007 vs. P=0.228). The incidence of fatal arrhythmias in the streptokinase group was lower than in the others. The relationship between the incidence of VT/VF and TIMI flow grade was insignificant (P=0.089). Reduction of the door to needle time after anterior MI has significant effects on QTc and incidence of threatening arrhythmia.

Corticospinal Tract Hypoperfusion Associated With Unexplained Early Neurological Deterioration After Intravenous Thrombolysis.

Background and PurposeEarly neurological deterioration (END) occurs in 10% among patients with acute ischemic stroke (AIS) who are receiving intravenous thrombolysis (IVT). Over half of them have no straightforward causes, which is referred to as unexplained END. We aimed to explore whether the presence of baseline corticospinal tract (CST) hypoperfusion could predict the development of unexplained END at 24 h in patients with AIS after receiving IVT.MethodsWe retrospectively analyzed the clinical and imaging data from patients with AIS who received IVT. Unexplained END was defined as ≥ 2-point increase of National Institutes of Health Stroke Scale (NIHSS) from baseline to 24 h without straightforward causes. Hypoperfusion lesions involving CST and other cerebral areas were identified on perfusion maps.ResultsAmong 807 patients, CST hypoperfusion and non-CST hypoperfusion occurred in 488 (60.5%) and 319 (39.5%) patients, respectively. Patients with CST hypoperfusion were more likely to have unexplained END compared with patients with non-CST hypoperfusion (16.6 vs. 2.8%, P < 0.001). Binary logistics regression analysis showed that CST hypoperfusion was independently associated with unexplained END after IVT (OR = 5.64; 95% CI: 2.699–11.785; P < 0.001) after adjusting for baseline NIHSS, onset to needle time, baseline hypoperfusion volume, atrial fibrillation, and hypertension.ConclusionsPatients with CST hypoperfusion were more likely to suffer from unexplained END after IVT, implying potential mechanisms and potential prevention of unexplained END.

Acute ischemic stroke thrombolysis- experience from a rural hospital in Kerala, India

Outcome assessment of thrombolysis with intravenous rt-PA in acute ischemic stroke.All patients with acute ischemic stroke patients who underwent IV thrombolysis with rt-PA from January 2019 to December 2021 were studied retrospectively. Clinical efficacy outcome was the favourable outcome on modified Rankin scale at 90 days defined as a score of ≤2. During our study period, a total of 50 patients with ischemic stroke thrombolysis underwent intravenous recombinant tissue plasminogen activator (rt‑PA). The study consisted of 33 males and 17 females with a mean age of 64.82 ( 12.21 standard deviation) years. The median time from onset of symptoms to IV rt-PA administration was 120 minutes (interquartile range 90 - 160). The mean door to needle time was 50.1 ( 21.32 SD) minutes. Favourable outcome (mRS score ≤2) was observed in 38 patients (76%) at three months’ follow-up. Poor outcome (mRS score &amp;#62;2) was seen in the remaining 12 patients (24%).Large artery atherosclerosis had the most favourable outcome followed by small vessel occlusive stroke. Factors predicting favourable outcome in our study were age &amp;#60;60 years (p = 0.03), female gender (p &amp;#60; 0.001) and large vessel occlusion (p &amp;#60; 0.001). Factors predicting poor outcome were hypertension (p &amp;#60; 0.001), dyslipidemia (p = 0.01), prior stroke (p &amp;#60; 0.001) and symptomatic haemorrhage (p = 0.02). Ischemic stroke patients can be thrombolysed in a safe and effective even in rural settings if proper institutional protocol is formulated and its implementation is ensured.

Rt-PA thrombolytic therapy in patients with acute posterior circulation stroke: A retrospective study.

At present, recombinant tissue-type plasminogen activator (rt-PA) thrombolytic therapy is widely used in patients with acute ischemic stroke within 4.5 h following stroke onset. However, the efficacy of intravenous alteplase thrombolytic therapy for posterior circulation stroke (PCS) has been rarely described. The present study aimed to predict the outcome of patients with PCS following rt-PA thrombolytic therapy in a more efficient manner. Data were collected from patients who had suffered from posterior circulation ischemic stroke, who had been treated with rt-PA over a period of 4 years (2016-2020), and had been treated at a stroke center. All patients were treated with alteplase at a standard dose of 0.9 mg/kg. According to the onset to needle time (ONT), these patients were divided into the 0-3 and 3-4.5 h groups, and the National Institutes of Health Stroke Scale (NIHSS) score was compared before thrombolysis and at 24 h after thrombolysis. Subsequently, the patients with acute PCS whose ONT was ≤3 h were divided into the NIHSS score >3 points and NIHSS score ≤3 points groups, and the NIHSS score improvement rate was compared 24 h later. A total of 989 patients were included in the study; there were 783 patients with acute anterior circulation stroke (ACS) and 203 patients with acute PCS (of note, 2 patients had negative results from brain magnetic resonance imaging); 63 patients were treated with urokinase (UK) thrombolysis and 140 patients were treated with alteplase intravenous thrombolysis. The 140 patients that received alteplase thrombolytic therapy were divided into two groups, namely the ≤3 h group and 3-4.5 h group, which, on the basis of the ONT, no significant differences were found between the two the groups according to the NIHSS score before thrombolysis (P>0.05). The NHISS scores in the ≤3 h group were significantly lower than those in the 3-4.5 h group following thrombolysis therapy, and the differences between the two groups were statistically significant (P<0.05); the patients with acute PCS treated with rt-PA in the ≤3 h group were divided into the NIHSS score ≤3 points group and the NIHSS score >3 points group. In this ≤3 h group, the average NIHSS score improvement rate following rt-PA thrombolysis was 0.535 (53.5%) in the NIHSS score ≤3 points group and that in the NIHSS score >3 points group was 0.336 (33.6%); the difference between the two groups was statistically significant (P<0.05). The patients treated with intravenous alteplase thrombolysis within 3 h following stroke onset benefited more than those treated with thrombolysis therapy within 3 to 4.5 h after stroke onset. On the whole, the present study demonstrates that the patients with mild stroke (NIHSS score ≤3 points) who were treated at an earlier stage (received alteplase thrombolysis therapy within 3 h after stroke onset) benefited to a greater extent from the therapy.

Abstract WP49: Mri Based Thrombolysis For Unwitnessed Stroke Patients Is Feasible At Primary Stroke Centers

Background: The 2018 WAKE-UP Trial established the safety and efficacy of administering IV-tPA in patients who presented within 4.5 hours of symptom discovery based on specific MRI sequences. Implementation of the study results remains limited at Primary Stroke Centers (PSCs). We assessed the feasibility of a Comprehensive Stroke Center (CSC) MRI based unwitnessed thrombolysis protocol at 13 PSCs. Methods: A committee consisting of vascular neurologists, neuroradiologists and MRI technologists developed the protocol. The protocol was utilized at the CSC for one year, and subsequently expanded to the PSCs. A specific "WAKE-UP MRI”" order was created which consisted of only DWI, GRE and FLAIR sequences. MRI technologists were trained to ensure that the "WAKE-UP MRI” would take priority over other patients; eg: if there was no one in MRI, it would be held for the stroke patient, and if MRI was occupied, the stroke patient would be next. The acute stroke care was managed by an integrated telestroke system at the PSCs. All telestroke providers were educated on the protocol. Standard stroke time metrics were collected and analyzed over 2 years. Data from the CSC was compared with its 13 PSC spokes. A student’s t-test was used for data analysis. Results: A total of 190 patients who arrived with 4.5 hours of symptom discovery were screened; 62 at CSC and 128 at PSCs. Forty underwent emergent MRI at CSC and 29 at PSCs. Median door to MRI time was longer for patients presenting to PSC compared to CSC (78 vs 53.5 mins; p = 0.0002). Twenty-one vs 9 patients received tPA at CSC and PSC hospitals respectively. Median door to needle (DTN) times were longer for patients at PSC vs CSC (106 vs 67 mins; p = .018). The most common reasons for not administering IV-tPA was a negative MRI (40% at PSCs vs 47% at CSC) and a lack of DWI and FLAIR mismatch (40% at PSCs vs 42% at CSC). Conclusion: Use of emergent MRI in unwitnessed stroke for thrombolysis is feasible at PSCs. There remain barriers to implementation, with PSCs showing more delayed access to MRI and thrombolysis compared to CSC.

Abstract NS4: Dizziness In Stroke: Triage Nurses Identify Posterior Circulation Strokes In A Comprehensive Stroke Center Emergency Department Using Three Simple Questions

Introduction: Recognition of stroke alerts in triage are imperative to the rapid evaluation of acute ischemic stroke. Patients who present to the Emergency Department (ED) with a chief complaint of dizziness have historically been challenging for triage nurses. Missed triage opportunities may result in increased door to needle (DTN) times. The goal of this study was to assess if a dizziness triage tool can reduce missed posterior circulation strokes and decrease DTN times. Methods: We developed the following three questions: Is the room spinning, shaking, or are you lightheaded; does it come and go or is it persistent with sudden onset within the last six hours; does the dizziness change with position. If the description of dizziness was sudden, spinning/shaking, persistent, and non-positional, then the patient was triaged as a stroke. ED RNs were trained and education tools were distributed in January 2019. Data were retrospectively reviewed on patients who presented with dizziness, were diagnosed with posterior circulation strokes, and received IV Alteplase. Dizziness for this study was defined as: dizziness, dizzy, vertigo, lightheaded, room spinning, room shaking, unsteadiness, and/or imbalance. Data were reviewed pre and post implementation over a three-year period to assess the percentage of patients captured by the tool and its impact on DTN times. Data were analyzed using a t-test. Results: Patients with a Brain Alert were older (71 {IQR 59-74}) vs. No Brain Alert (57 {IQR 53-63} p=0.036) yrs. 86% of women had no brain alert whereas 62% of men did. The median NIHSS for Brain Alert was 3 (IQR 1-4) vs. no brain was 1 (IQR 1-4) (p=0.89). In the pre-implementation time frame 47% (7/15) of dizzy patients diagnosed with ischemic stroke and received alteplase were captured by a triage nurse activated brain alert. Post implementation 89% (8/9) and 100% (4/4) were captured in 2019 and 2020 respectively. Median DTN for dizzy patients improved from 56 mins in 2018 (IQR 44-92) to 46 mins in 2020 (IQR 36-60) p=0.025. Conclusion: A triage nurse three-question dizziness tool is successful and sustainable in identifying posterior circulation strokes in the emergency department which helps to decrease DTN times in these patients.

Abstract TMP36: Improve Patient Outcomes In A Specialized Neurological Emergency Department

Improved Patient Outcomes In A Specialized Neurological Emergency Department Introduction: Stroke is now the fifth leading cause of death in the U.S., but remains the leading cause of long term disability. Target: Stroke helps hospitals achieve improved stroke outcomes through reduced door-to-needle times for eligible stroke patients. Phase III of the American Heart Association/American Stroke Association initiative set more aggressive targets for timely treatment with IV alteplase. To achieve rapid treatment times and better patient outcomes, we created a neurologic emergency department (Neuro ED). Neuro ED hours are staffed by emergency physicians with specialized neuroscience training and administer IV alteplase independently, compared to the traditional ED (TED) where emergency providers consult neurology. Methods: This is a retrospective observational study from 2019-2021 comparing outcomes of acute ischemic stroke patients who received IV alteplase following implementation of the Neuro ED compared to a TED. The following metrics were calculated for each patient: Door to Needle times (DTN), door to CT times (DTCT), and pre and post National Institute of Health Stroke Scale (NIHSS) Results: 74 patients were treated in the Neuro ED and 45 patients were treated in the TED. Average DTN times in the Neuro ED were 27 minutes compared to 65 minutes in the TED. Patients treated in the Neuro ED achieved DTN times of 45 min or less 87% of cases, while only 24% of the time in the TED. Patients treated in the Neuro ED achieved DTN times of 30 min or less 65% of cases, with only 4% of cases in the TED. Average DTCT times in the Neuro ED were 8 minutes faster than the TED. No differences in admission NIHSS were found with an average of 8.75, but a significant improvement was found in discharge NIHSS. Average discharge NIHSS was 3.8 for Neuro ED stroke patients compared with 5.6 for TED patients (p&lt;0.001). Conclusion: Implementation of a Neuro ED led to swift management and improved symptoms for stroke patients. A dedicated Neuro ED is highly effective in improving DTN times, DTCT times, and overall stroke outcomes.

Abstract WMP30: How To Beat The Metrics With Telestroke: A Community Hospital Primary Stroke Center Experience

Background and Issues: A community hospital primary stroke center (PSC) faced many challenges including inconsistent local neurology coverage as well as inefficient in-hospital workflows. This led to a decrease in number of patients treated with IV thrombolytics, a decline in meeting stroke metrics, and challenges in maintaining PSC certification. Purpose: To implement a Telestroke system of care that would provide advanced acute stroke management in a community hospital with the goal of improved stroke workflows, stroke metrics, and quality of care. Methods: In 2019 a 172-bed community hospital PSC collaborated with a Telestroke program at a Comprehensive Stroke Center. This collaboration led to significant changes including ED physician leadership, standardized protocols with an increase in stroke alerts, EMS engagement, pre-mixing thrombolytics, dedicated stroke coordinator and education of all key personnel. The primary outcome measures were volume of stroke alerts, rate of thrombolytic use, and median door to needle before and after telemedicine implementation. Results: After one year of Telestroke utilization, the number of stroke alerts increased from 88 in 2018 to 256 in 2020 (290% increase). The number of patients receiving thrombolytics increased by 440% (10 in 2018 to 44 in 2020). Median door to needle time decreased from 56 mins in 2018 to 41 mins in 2020, an improvement of 15 minutes. Conclusions: Telestroke is a consistent and effective way to assess patients with suspected acute stroke in a community hospital setting. Key factors to its successful implementation include dedicated ED physician leadership, consistent protocol application, education and data sharing for motivation and continuous process improvement. In conclusion, Telestroke use increased access to stroke neurologists and improved thrombolysis rates and stroke outcomes.

Abstract WP5: Bundling Of Head Computed Tomography Scan And Head And Neck Computed Tomography Angiogram At Initial Telestroke Consultation Is Associated With Faster Thrombectomy Transfer And Treatment Times

Introduction: Telestroke has expanded access to tPA and thrombectomy for acute ischemic stroke and improved neurologic outcomes. A key step in the evaluation of acute stroke is non-contrast head CT (HCT) and head and neck CT angiogram (CTA). These imaging studies can either be bundled at presentation, or a delayed CTA may be performed after a tPA decision based on HCT alone. Bundled imaging may facilitate faster transfer and treatment times, while delaying tPA. We investigated the effect of bundled imaging on thrombectomy transfer and treatment times in our telestroke network. Methods: We reviewed patients in our telestroke network from 2019-2021. We included patients who had received HCT and CTA at a partner hospital prior to transfer to our comprehensive stroke center (CSC) for thrombectomy. We collected baseline clinical variables, and timing of imaging, transfer and treatment relative to time of initial HCT. Patients were divided into a bundled imaging group (simultaneous HCT and CTA) or a delayed CTA group. Wilcoxon Rank sum test was used to compare between the two groups for HCT to tPA needle time, HCT to CSC arrival time, and HCT to Groin Puncture Time Results: 273 patients were assessed via telestroke in the study period. Of these 93 were included. 43 patients received bundled CTA, and 50 patients received a delayed CTA. 20 patients received tPA in the bundled group vs 25 in the delayed CTA group. Median CSC transfer time was lower with a bundled imaging strategy (110 min vs 160 min; p&lt;0.001), as was median time to groin puncture (174 min vs 242 min; p&lt;0.001). Further, there was no difference in tPA needle time (38 min vs 37 min; p=0.86). Conclusions: Bundled HCT and CTA at telestroke sites was associated with significantly faster transfer and groin puncture times for patients with large vessel occlusion. Further, obtaining the CTA prior to a tPA decision did not significantly prolong HCT-to-needle times.

Abstract 25: Tenecteplase Is Safe And Efficacious In Telestroke Patients With Confirmed Large Vessel Occlusions

Introduction: Tenecteplase has been demonstrated to be an effective option for thrombolysis in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Thrombolysis decision making is an important component of telestroke consultations. Data is scarce concerning tenecteplase usage in telestroke patients. We aimed to evaluate if tenecteplase was safe and feasible for patients with confirmed LVO in a large telestroke network. Methods: We conducted a retrospective analysis of AIS patients with LVO and treated with thrombolysis from May 2018 to April 2021. We compared outcomes in telestroke patients treated with IV alteplase (May 2018 - April 2020) to patients treated with IV tenecteplase (May 2020 - April 2021). We evaluated our primary efficacy and safety outcomes: 90 day functional outcome as measured by modified Rankin Scale (mRS) and complications related to thrombolysis. Secondary outcomes included door to needle time (DTN) and door in door out time (DIO). Ordinal regression assessed 90 day mRS and binomial logistic regression analysis evaluated complications between the groups. Quantile regression models assessed the median to compared groups for DTN and DIO. Results: There were 3747 telestroke consults during the study period and 537 (14.3%) were found to have an LVO, of which 109 (39 IV tenecteplase; 70 IV alteplase) were eligible, received thrombolysis and were included in this study. Patients treated with IV tenecteplase had significantly less disability at 90 days compared to patients treated with IV alteplase [1 (0 - 4.5) vs. 3 (1 - 6)], adjusted odds ratio (aOR) = 0.31 [95%CI, 0.14 - 0.72], p = 0.006, based on mRS ordinal shift analysis. Similar complication rates were reported between the thrombolysis groups, aOR = 3.73 [95%CI, 0.23 - 59.95], p = 0.35. An adjusted quantile regression model found IV tenecteplase was administered 9.40 minutes quicker, standard error (SE) = 3.67, [95%CI, 2.11 - 16.69] than IV alteplase, p = 0.01. There were no differences reported between thrombolysis groups and DIO, p = 0.63. Conclusion: Telestroke patients presenting with confirmed LVO and treated with IV tenecteplase were found to have better 90 day outcomes compared to patients treated with IV alteplase, without increased complication rates.

Abstract TP78: Team-based Resident Training For Stroke Code Simulations Decreases Variations In Thrombolytic Door To Needle Times

Introduction: Stroke code simulation training is effective at reducing door to needle times (DTNT) for tPA administration. We aimed to evaluate the effect on DTNT from simulation training specifically for Neurology residents. Method: Stroke code simulation was implemented at our comprehensive stroke center in July 2017, targeting PGY2 adult neurology residents and PGY3 pediatric neurology residents who were first responders at stroke codes during off-hours. Training was completed at the beginning of the residents’ respective training years. An interrupted time series analysis of DTNT for tPA before and after the implementation of simulation training from July 2016 to July 2019 was performed. Demographics, tPA metrics, and safety and hospital metrics were compared pre and post intervention among the residents. No other quality improvement projects targeting DTNT were implemented during this time. Results: Between July 2016 and July 2019, 305 patients received thrombolysis from a resident first responder - 118 (39%) of whom were treated pre-simulation and 187 (61.3%) treated during the simulation period. There was no significant difference in patient baseline characteristics between the two groups (Table 1). Median DTNT was 49.5 (IQR 40-71) min during the pre-simulation period and 48 (IQR 37-60) min during the post-simulation period (p= 0.04). Compared to pre-simulation, there were no months in which the median DTNT exceeded 60 min post-simulation. IQR for the DTNT appeared both clinically and statistically different. Pre and post simulation, there was no difference in incidence of symptomatic intracranial hemorrhage nor in 90-day outcomes. Conclusion: In our analysis of the effect of stroke code simulation training among neurology residents, improvement in DTNT after simulation training appears more driven by improvement in the variation in times rather than a clinically significant decrease in median times.

Abstract WP31: Really, Did A Code Stroke Simulation Improve Compliance In Patient Care Requirements?

Purpose: Enhance the care of ischemic stroke patients by improving compliance with implementation of appropriate order sets, following protocols addressing assessment of vital signs, neuro checks, and lowering door to needle times. Method: ED nurses were required to attend one of five simulation skills fair offered over a nine month period. A stroke simulation scenario was provided in the simulation lab. Groups of nurses performed each step in the care of a code stroke patient. An ED nurse facilitated each step to assure the staff had an understanding of time related events such as calling code stroke, identifying the exact time of last seen well, obtaining CT, vital signs, labs, neuro checks, scoring the patient, and administration of Alteplace, if applicable. Results/Outcomes: Metrics for fiscal year were compared to the statistics collected for the last quarter of fiscal year. Implementation of the stroke order set rose 56.4%, from 43.6% to 100%. Compliance with the protocol, neuro checks improved 40% to 90% and documentation of vital signs per protocol rose from 90% to 97%. Door to needle time improved by 11 minutes. Implications: The simulation educational intervention proved to show a significant improvement in compliance in performing vital signs, neuro checks, using stroke order sets and especially door to needle times. The ED leadership team has recognized the significant impact to our patient care outcomes and compliance resulting from providing this simulation education. The simulation also identified that the majority of the staff did not understand how to correctly perform neuro checks and were not placing the correct code stroke order sets that included the orders to do vital signs and neuro checks per protocol.

Controlled Subretinal Injection Pressure Prevents Damage in Pigs

Introduction: Administration of retinal gene and stem cell therapy in patients with retinal degenerative diseases is in many cases dependent on a subretinal approach. It has been indicated that manual subretinal injection is associated with outer retinal damage, which may be explained by a high flow rate in the injection cannula. In the present porcine study, we evaluated flow-related retinal damage after controlled subretinal injection at different flow rates. Methods: The flow rate through a 41G cannula was estimated at different injection pressures (6–48 pounds per square inch [PSI]) in an in vitro setup. A linear correlation between the flow rate and injection pressure was found from 6 to 32 PSI. In full anesthesia, 12 pigs were vitrectomized and received a controlled subretinal injection of 300 μL balanced saline solution at injection pressures of 14, 24, and 32 PSI (four in each group). Prior to surgery and 2 and 4 weeks after surgery, the eyes were examined by multifocal electroretinogram (mfERG) and fundus photographs. At the end of follow-up, the eyes were enucleated for histology. Results: The in vitro flow study determined that the flow in a 41G cannula shifts from laminar to turbulent at 32 PSI and that the manual injection flow is turbulent. In the porcine study, we showed a significant difference in retinal pigment epithelium (RPE) damage between the three pressure groups (p = 0.0096). There was no significant difference in damage to the outer retina (p = 0.1526), but the high-pressure group (32 PSI) had the most outer retinal damage. The middle-pressure group (24 PSI) showed minimum retinal damage. There was no significant change in the mfERG ratios during follow-up. Discussion/Conclusion: This study indicates that an injection pressure at approximately 24 PSI might be safe for subretinal delivery. Retinal damage at low injection pressures may be explained by mechanical damage to the RPE due to prolonged needle time in the subretinal space, while retinal damage at high pressures can be related to high flow in the injection cannula. Controlled subretinal injection pressure of 24 PSI showed minimum mechanical- and flow-related damage to the porcine retina.

Time Metrics in Acute Ischemic Stroke Care During the Second and First Wave of COVID 19 Pandemic: A Tertiary Care Center Experience from South India

BackgroundDuring the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave. MethodsWe did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS). ResultsFrom June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods. ConclusionOur study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim “Time is Brain” while restructuring stroke workflows during future challenges.

Impact of Delayed Pain to Needle and Variable Door to Needle Time On In-Hospital Complications in Patients With ST-Elevation Myocardial Infarction Who Underwent Thrombolysis: A Single-Center Experience.

BackgroundMyocardial infarction is a life-threatening event, and timely intervention is essential to improve patient outcomes and mortality. Previous studies have shown that the time to thrombolysis should be less than 30 minutes of the patient’s arrival at the emergency room. Pain-to-needle time is a time from onset of chest pain to the initiation of thrombolysis, and door-to-needle time is a time between arrival to the emergency room to initiation of thrombolytic treatment. Ideally, the target for door-to-needle time should be less than 30 minutes; however, it is unclear if the door-to-needle time has a significant impact on patients presenting later than three hours from the onset of pain. As many of the previous studies were conducted in first-world countries, with established emergency medical services (EMS) systems and pre-hospital ST-elevation myocardial infarction (STEMI) triages and protocols, the data is not completely generalizable to developing countries. We, therefore, looked for the impact of the shorter and longer door-to-needle times on patient outcomes who presented to the emergency room (ER) with delayed pain-to-needle times (more than three hours of pain onset). ObjectiveTo determine the impact of delayed pain-to-needle time (PNT) with variable door-to-needle time (DNT) on in-hospital complications (post-infarct angina, heart failure, left ventricular dysfunction, and death) in patients with ST-elevation myocardial infarction (STEMI) who underwent thrombolysis.Methods and resultsA total of 300 STEMI patients who underwent thrombolysis within 12 hours of symptoms onset were included, which were divided into two groups based on PNT. These groups were further divided into subgroups based on DNT. The primary outcome was in-hospital complications between the two groups and between subgroups within each group. The pain-to-needle time was ≤3 hours in 73 (24.3%) patients and >3 hours in 227 (75.7%) patients. In-hospital complications were higher in group II with PNT >3 hours (p <0.05). On subgroup analysis, in-hospital complications were higher with longer door-to-needle time in group II (p<0.05); however, there was no difference in complications among group I.ConclusionOur study is consistent with the fact that shorter door-to-needle time, even in patients with delayed PNT (>3 hours), has a significant impact on in-hospital complications with no difference in mortality.