Needle Time Research Articles

Abstract TP81: Healthcare Disparities For Thrombolysis In Patients Presenting With Stroke-like Symptoms At A Comprehensive Stroke Center

Background: Stroke is a leading cause of death and disability. Early presentation allows clinicians to use tPA for acute stroke therapy to improve outcomes. However, healthcare disparities among different racial/ethnic and gender groups remain a limitation for uniform access to acute stroke therapy. We investigated if such gender and racial disparity exist in tPA administration at a large community comprehensive stroke center (CSC). Methods: Retrospective analysis of a prospective cohort of patients was conducted of patient with acute stroke symptoms who presented to a CSC between May 2018 and May 2022. Demographics, time from last known normal (LKN), rate of tPA administration and door to needle time (DTN) was calculated. Univariate analysis between groups was performed using one-way ANOVA for mean, Kruskal-Wallis test for median and p-value <0.05 was considered significant. Results: Total number of patients presenting to our CSC during the study period with stroke like symptoms was 3901. Of this index cohort, 401 (10.2%) were administered tPA - 207 (51.6%) women and 194 (48.3%) men. Women were significantly older [67.5 ± 15.1 years compared to men, 62.6 ± 13.3 years (p=0.027)]. Average time of LKN to arrival was 124 ± 3.8 min for women and 130 ± 4.9 min for men (p=0.298). Black women’s DTN was longer compared to white women ( 50.9 ± 3.15 min v. 41.5 ± 2.07 min, p=0. 0103). However, proportion of Black women receiving tPA did not differ from white women [87/770 (11.3%) v. 113/1041 (10.9%), p=0.824]. Race disparity was noted among Black men compared to white men for tPA administration [64/798 (8.0%) v 119/1226 (9.7%), p=0.018]. No gender or racial disparity was noted among tPA recipients regarding mRS at discharge [white men v. white women v. Black men v. Black women - 2 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4) v. 3 (IQR 1,4), p=0.211]. Conclusions: At a large volume, urban, non-academic comprehensive stroke center, overall gender, or racial factors were similar for discharge outcome. However, a delay in tPA administration among Black women and lower incidence of tPA administration in Black men compared to their respective white counterparts need to be validated in larger registries.

Abstract WP31: Driving Down Door To Needle Time: ED Stroke Leadership's Commitment To Continuous Improvement

Background: In March 2019, our 126 bed community hospital received Primary Stroke Center Certification. The Emergency Department (ED) Stroke Leadership Team was tasked with the responsibility of identifying opportunities for process improvement and implementing changes within the ED. Purpose: The purpose of this poster is to illustrate the ED Stroke Leadership Team’s commitment to continuous improvement ultimately reducing EMS Door to Needle time. Method: Data was obtained through retrospective case review of patients who arrived via EMS and received IV thrombolysis for acute ischemic stroke in the ED, between April 2019 and June 2022. Process improvement data was reviewed monthly and interventions were implemented at various intervals using the Plan-Do-Check-Act (PDCA) method. Some early interventions included but were not limited to: EMS pre-notification, a broadcasted stroke alert for all ED staff including pharmacy and CT, and the creation of an EMS direct to CT process. January 2022, the ED Stroke Leadership Team began their 4 th cycle of the PDCA. In addition to changing the IV thrombolytic from alteplase to tenecteplase, the team took the opportunity to make additional changes to the process and provided education of the stroke protocols and measures to the staff. Results: The ED began receiving stroke patients via EMS in April 2019. At the end of 2019 a total of 13 stroke patients arrived via EMS with 5 patients receiving IV thrombolytic therapy with a median Door to Needle baseline of 51 minutes. In 2020 & 2021 EMS stroke pre-notifications increased to 30 and 72 patients respectively but the IV thrombolytic was given to a two year combined total of 9 patients with a median Door to Needle time of 41 minutes. January 2022 we began to see a rise in the volume of stroke patients. As of June 2022, EMS delivered 53 patients in which 9 received IV tenecteplase with a median Door to Needle time of 28 minutes. These incremental process improvements represent a 45% decrease in EMS Door to Needle over the last 3 years. Conclusions: In conclusion, the ED Stroke Leadership Team’s commitment to continuous improvement has been the driving factor in the reduction of the EMS Door to Needle time.

Abstract TP32: Continuous Quality Improvement Implementation Across A Stroke Network

Background and Purpose: One of the network missions is to improve quality of care through an evidence-based, standardized approach. In 2014 with 24 affiliate hospitals (25% certified stroke centers), a formalized continuous quality improvement process began and it continues through today with 37 affiliate hospitals (51% certified stroke centers). Methods: Over the years, the quality process has been enhanced to include additional abstraction training/support, individual data points for improved data analysis and a newly developed data report with built in logic and automatically populated graphs. Data is aggregated for network analysis and an annual scorecard is published that is utilized for benchmarking. Performance improvement (PI) goals are established as a network. Results: In 2014, 88% (21 of 24) affiliates submitted stroke data, compared to 91% (32 of 35) in 2022 fiscal year (Note: two affiliates are pending training). In 2022, 80% of non-certified stroke centers submitted data, compared to 100% for certified stroke centers. For Thrombolytic Therapy (STK-4), 79% compliance rate in 2014, compared to 89% in 2022; Thrombolytic Therapy (ASR-OP-1), 66% compliance rate in 2021, compared to 88% in 2022. For Dysphagia Screening (STK[PM]-7), 58% of the affiliates submitted data in 2014 with average of 92% compliance, compared to 89% in 2022 with an average of 87%. For Order Set Usage, in 2018 61% of the affiliates submitted data with an 87% compliance rate, compared to 89% of the affiliates submitted data with an 87% compliance rate in 2022. From 2018 to FY2022, the network had a 10% improvement in Door to Needle (≤ 60 minutes) from 66% compliance to 76%. Conclusions: The network showed improvement with the CQI program in: data submission rates, Door to Needle Time, and Thrombolytic Therapy. This is a success overall, particularly with the non-certified stroke centers. Though there are many confounding factors, this is in correlation with our focused improvement efforts such as individual follow-ups, data abstraction training, quarterly review of data, sharing best practices, updating program documents, monthly quality insights and education with affiliates.

Abstract TP75: Waking Up To A New Wake-Up Stroke Protocol Is Feasible And Safe

Introduction: Up to 25% of strokes are recognized upon awakening. Recent studies have demonstrated that a “tissue clock” rather than a time clock can be used to identify patients who may benefit from intravenous thrombolytics (IVT) beyond 4.5 hours from last known well (LKW). Consistent access to hyperacute MRI limits many centers from treating wake-up stroke patients. We created a formal protocol of clinical and imaging criteria to standardize evaluation and management of wake-up strokes. Methods: This retrospective, observational study reviewed consecutive patients admitted to our Comprehensive Stroke Center who qualified for the wake-up protocol between February 2022 and June 2022. The implemented protocol, based on clinical trials’ inclusion criteria, is comprised of the following: 1) arrival within 12 hours from LKW and within 4.5 hours from symptom discovery; 2) high suspicion for acute ischemic stroke; 3) no contraindication to MRI; 4) NIHSS of at least 4; 5) baseline mRS 0-3; 6) no absolute contraindications to IVT. For patients meeting above inclusion criteria, emergent MRI with perfusion was performed. Diffusion-FLAIR mismatch (signal intensity ratio) and diffusion-perfusion mismatch were reviewed to determine thrombolysis eligibility by a trained neuroradiologist or vascular neurologist. Results: Ten patients qualified for the wake-up protocol in the first five months of protocol implementation. Median NIHSS was 7, median LKW to arrival time was 8 hours, and median door to MRI time was 72.5 minutes. A final diagnosis of ischemic stroke was made in 80% of these cases. Overall, 50% were eligible for IVT based on our criteria, and 30% received thrombolysis. Median door to needle time was 92 minutes (range 75-117). There were no symptomatic intracranial hemorrhages. All patients treated with IVT were discharged home with no to minimal residual deficits with mRS 0-1 and median NIHSS at discharge of 2 (range 0-4). Conclusion: A formal protocol for wake-up stroke management allowed a streamlined approach to expand the number of IVT-eligible cases. Continued efforts are needed to improve door to needle times in such cases and to follow clinical courses of treated patients.

Reducing seizure to needle times in nonconvulsive status epilepticus with multifaceted quality improvement initiatives

ObjectivesDelayed management of nonconvulsive status epilepticus (NCSE) can lead to an increased morbidity and mortality. We previously established that inefficient treatment of NCSE at our institution stemmed from delayed initiation of emergent anti-seizure medications (ASM). In the present study, we assessed the trajectories of these time parameters and determined patient outcomes following the specific quality improvement (QI) interventions. MethodsThe QI interventions, including the revision of the educational content for trainees and pharmacy workflow optimization were implemented between January 2019 and September 2021 by a dedicated multidisciplinary task force. The times needed to initiate and administer the ASMs for patients with NCSE as well as patient mortality were assessed in comatose and noncomatose patients and compared with the corresponding values prior to the interventions. ResultsThere were 79 occurrences of NCSE in 74 patients. The median time from seizure detection on EEG to the order of the first and second ASM for NCSE was reduced by 4 (p = 0.83) and 8 min (p = 0.52), respectively compared to the times prior to the initiation of interventions. The median times from the order to administration of the first and third ASM for all NCSE occurrences were reduced by 8 and 10 min, respectively (p = 0.28 and p = 0.10). In the present cohort of comatose patients, the median time spent to order the first ASM was reduced by 16.5 min and the time to administer it reduced by 35 min compared to that in our previous study. The overall patient mortality was decreased by 11.1%. SignificanceMore efficient delivery of rescue ASMs in patients with NCSE and improvement in their mortality can be achieved with multidisciplinary team efforts aimed at streamlining the functioning of pharmacy and strengthening the education of trainees and nurses.

Optimizing door to needle time in children with febrile neutropenia in the emergency room- A quality intervention study

Optimizing door to needle time in children with febrile neutropenia in the emergency room- A quality intervention study

Door to Needle Time in Acute Ischemic Stroke Patients before and after Initiation of Quality Improvement Project - Single Local Centre Experience

Background and Aims: Thrombolysis has been shown to improve stroke outcomes by reducing disability, particularly when administered early. Lowering the door-to-needle time (DNT) for administering intravenous thrombol¬ysis (IVT) is an important objective for improving the quality of acute stroke care. This study aims to compare DNT before and after implementing the code stroke pathway protocol. Methods: The study evaluated the impact of a quality improvement project, Code Stroke, on acute ischemic stroke patients at King Fahd General Hospital in Jeddah, Saudi Arabia, September 2019 to April 2020, using a retrospective record-based analysis, with data extracted using a standardized format and cat¬egorized into pre and post code groups. Results: 81 stroke patients were reviewed, with 47 in the pre-code group and 34 in the post-code group. The re¬ported tPA DNT time was less than 60 minutes in only 8.5% of patients before the implementation of stroke code activation, compared to 55.9% after implementation (p=.001). Incidence of symptomatic hemorrhagic transformation was 8.6%. Post-code group had a lower median length of hospital stay (8 days) compared to the pre-code (13 days), with a marginal trend towards statistical significance, and half of the post-code group patients had a modified Rankin Scale of 0-2 compared to one third of the pre-code group at three months of discharge. Conclusions: The Code Stroke project resulted in a significant reduction in DNT, improved functional outcomes, and a reduction in hospital length of stay, but the incidence of symptomatic intracranial hemorrhage and in-hospital mortality rates were slightly higher than expected, requiring continued improvement efforts.

A STUDY OF INCIDENCE OF ACUTE KIDNEY INJURY IN SNAKE BITE

Background Snakebite is one of the commonest occupational hazards in our country, especially among the rural population. It leads to a multitude of complications starting from localized cellulitis to even death. AKI is a signicant as well as an under reported complication in patients of snake bite which has a tremendous impact on the nal outcome. The unfavourable outcome in snake envenomation can be predicted early with the development of AKI. In this study, we wanted to assess the clinical prole of snakebite patients and determine the incidence of AKI in patients of snakebite. Aim 1. To study the incidence of acute kidney injury in patients following snake bite. 2. To study the clinical and renal prole in patients following snake bite with AKI. Study Design This was a prospective observational study conducted in a teaching hospital over a period of 12 months. Materials And Methods The study included 100 patients of snakebite admitted in the Department of Medicine, Rajah Muthiah Medical College & Hospital done over duration of 12 months. The various data regarding clinical features of the patients, serum creatinine levels, other blood parameters of the patients selected for participation in the study were analysed using simple statistical methods. Majority of the snakebite victims were males. 30 % (N = 30 Results ) of the cases developed AKI. The mortality in patients of snakebite developing AKI was 25 % (n = 4). From our study Conclusion we conclude that, the most common manifestation of snake bite was cellulitis (95%) followed by regional lymphadenopathy (60%). The incidence of acute kidney injury in snake bite patient was 30% (N=30). Abnormal coagulation prole was present in 36.6% (N=11) patients with acute kidney injury. Bite to needle time more than 6 hours, oliguria, bleeding manifestations have signicant association with acute kidney injury. Snakebite envenomation is associated with a considerable burden of AKI in the developing countries especially among the rural population. Prompt initiation of aggressive treatment improves the nal outcome.

788: ANDEXANET ALFA (ANDEXXA) REVIEW OF EFFICACY, SAFETY, AND TIME TO PATIENT ADMINISTRATION

Introduction: The 2022 Management of Patients with Spontaneous Intracranial Hemorrhage guideline recommends the use of andexanet alfa as an option for patients taking apixaban or rivaroxaban to reverse the anticoagulant effects. In the ANNEXA-4 trial, 82% of the patients evaluated achieved either excellent or good hemostatic efficacy 12 hours after the andexanet alfa infusion. The use of andexanet alfa is restricted at our institution to the treatment of intracranial hemorrhage in patients previously on rivaroxaban or apixaban asordered by neurocritical care providers. The primary objectives for this evaluation were to determine the hemostatic efficacy 24 hours post andexanet alfa infusion and the time from andexanet alfa order to administration. Secondary endpoints included the rate of thromboembolic events, 30-day mortality, and adherence to prescribing restriction protocol. Methods: This was a single-center, retrospective medication use evaluation that assessed patients prescribed andexanet alfa from November 2018 to December 2021. Results: A total of 30 patients were prescribed andexanet alfa with 26 patients included in the analysis. Four patients were excluded due to the drug being ordered but not administered. Most patients were on apixaban prior to admission for atrial fibrillation indication (n=22, 85%). All included patients received low dose andexanet alfa, with the most common indication for reversal being intracranial hemorrhage (n=25, 96%).One patient received andexanet alfa for hemoperitoneum bleed reversal indication. Hemostatic efficacy was assessed and 61.5% achieved a rating of good or excellent as defined by the ANNEXA-4 trial. The average time from andexanet alfa order to administration was 53.2 minutes and the average door to needle time was 2.5 hours. Adverse events, including thromboembolic events and inpatient mortality, occurred in 0 and. Conclusions: In our study, patients admitted with intracranial hemorrhages secondary to apixaban or rivaroxaban use who received andexanet alfa for emergent reversal had excellent hemostatic outcomes with a low rate of adverse events. Most patients received andexanet alfa within an hour of order entry into the electronic health record and adhered to institutional prescribing restrictions.

Comparing performance measures and clinical outcomes between mobile stroke units and usual care in underserved areas

BackgroundThe efficacy of mobile stroke units (MSUs) in improving acute ischemic stroke (AIS) care in developing countries is unknown. We compared performance measures and stroke outcomes in AIS patients between MSU and usual care: emergency medical services (EMS) and walk-in.MethodsWe enrolled patients > 18 years of age with an AIS within 4.5 h after onset. Demographic data, types, and time of reperfusion therapies and clinical outcomes were recorded. A favorable outcome was defined as a modified Rankin Scale (mRS) 0–2 at 3 months.ResultsA total of 978 AIS patients (MSU = 243, EMS = 214, walk-in = 521) were enrolled between June 1, 2018, and April 30, 2021. The mean age (± SD) was 66 (± 14) years, and 510 (52.1%) were male. AIS time metrics were the shortest in the MSU with a mean (± SD) door to needle (DN) time of 20 (± 7), 29 (± 13), and 35 (± 16) min (p < 0.001) and door to puncture (DP) time of 73 ± 19, 86 ± 33, and 101 ± 42 min (p < 0.001) in MSU, EMS, and walk-in, respectively. Participants in the MSU (56.8%) received higher rate of reperfusion therapie(s) when compared to the EMS (51.4%) and walk-in (31.5%) (p < 0.001). After adjustment for any potential confounders and using the EMS as a reference, the MSU has the highest likelihood of achieving a favorable outcome (adjusted OR 2.15; 95% CI 1.39–3.32).ConclusionsIn underserved populations, MSUs significantly reduced DN time, increased the likelihood of receiving reperfusion treatment, and achieved independency at 3 months when compared to usual care.

Peripheral Nerve Stimulator Versus Ultrasound-Guided Femoral Nerve Block for Knee Arthroscopy Procedures: A Randomized Controlled Trial

Background Femoral nerve block (FNB) provides effective analgesia and is a widely used technique for postoperative pain relief for orthopedic procedures on lower limbs. This study aims to compare the efficacy of ultrasonography (USG) versus peripheral nerve stimulator (PNS)-guided FNB in knee arthroscopic procedures. Methodology This randomized comparative study included two study groups with 30 participants in each group who were given FNB with either PNS or USG for knee arthroscopic procedures following spinal anesthesia. The study evaluated the number of needle repositioning, the time taken for performing the block, the efficacy of postoperative analgesia based on the duration of the block, and patient satisfaction. Results The number of needle repositioning and time taken to finish the procedure using USG was lower compared to the group using PNS (p < 0.001). The duration of the block was comparable in both groups (p = 0.584). Patients were satisfied with both techniques and responded as either very good or outstanding and chose neither as inferior (p = 0.310). Conclusions Both techniques have equal efficacy concerning the duration of the effect of the block and patient satisfaction. However, the procedural time and number of needle repositioning were significantly less in the group where USG was used for the block.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis.

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

Potential mechanisms of acupuncture in enhancing cerebral perfusion of ischemic stroke.

Ischemic stroke is the predominant cause of long-term disability and death worldwide. It is attributable to the sudden interruption of regional cerebral blood flow, resulting in brain cell death and neurological impairment. Acupuncture is a widely used adjuvant treatment for ischemic stroke in China and shows promising efficacy in clinical practice. This review mainly focused on the evidence to illustrate several possible mechanisms of acupuncture therapy on cerebral perfusion in ischemic stroke. Studies have shown that acupuncture is probably effective in the enhancement of cerebral perfusion after ischemic stroke. It promotes the improvement of hemodynamics, the release of vasoactive substances, the formation of new blood vessels, as well as the restitution of microcirculation. Multiple factors may contribute to the variability in acupuncture's therapeutic effects, including the acupoint selection, stimulation frequency and intensity, and retaining needle time. Acupuncture has the potential to become a non-pharmacological adjuvant approach to enhance cerebral perfusion in ischemic stroke. Future studies are required to gain our insight into acupuncture as well as accelerate its clinical translation.

215 Fixed-dose vs. Weight-Based 4-Factor Prothrombin Complex Concentrate Dosing for Reversal of Warfarin-induced Intracranial Hemorrhage

215 Fixed-dose vs. Weight-Based 4-Factor Prothrombin Complex Concentrate Dosing for Reversal of Warfarin-induced Intracranial Hemorrhage

Comparison between fibrinolyzed stroke that arrived with the emergency service or other means

AimAnalyze the relationship between attendance times and health outcomes of people with ischemic stroke treated with intravenous fibrinolysis, comparing those attended from the emergency units of 061 ARAGON with those arriving by other means. MethodCross-sectional, retrospective, descriptive and association study based on a consecutive series of patients treated at the Miguel Servet University Hospital in the period 2014−16, analysing the time of care up to fibrinolysis and results of intravenous fibrinolysis, in terms of mortality and functional status at discharge. We also analysed the influence on attendance times of the protocol change that was carried out in 2016 and that included the direct warning to neurologists, instead of the receiving emergency, as before. ResultsA total of 231 patients with stroke were collected and treated with intravenous fibrinolysis. The mean age of the patients was 75.91 (±12.48). Women accounted for 52.8% of those fibrinolysed, the average age of men being lower [74.07 (±13.71) years, compared with 77.55 (±11.07) years for women]. The mean score on the NIHS scale at admission between the two groups presented significant differences (p = 0.006), being greater the affectation among those who arrived with 061 [NIHSS 13.20 ± 6.78 vs 10.7 ± 6.22]. In the comparison of times between patients who arrive or not with 061, the average time to hospital was 91.42 (±59.64) vs 93.20 (±83.73) (p = 0.731), without significant differences. However, there were significant differences in the time door needle (p = 0.046), noting that patients who are brought by 061 Aragon have better in-hospital time until fibrinolysis (better door-needle time) (67.19 (±26.03) vs 77.83 (±38.35).In the analysis of the door needle time by years, significant differences were observed (p < 0.001), being shorter each year, with a clear shortening in 2016 compared to previous ones, reflecting the impact of the update of protocols in this time period. ConclusionsThe patients brought in by 061 were different (more affected), fibrinolysed in a greater percentage and faster. Direct notice to neurologists significantly shortened attendance times. In terms of mortality and functional status at discharge, there were no differences between the two groups.

Comparison of sitting and prone positions for real-time ultrasound-guided thoracic epidural catheter placement: a randomized controlled trial

IntroductionReal-time ultrasound-guided thoracic epidural catheter placement (US-TECP) has been recently introduced. Patient’s position is associated with the success of spine interventions; however, the effects of position on the outcome of...

The Impact of COVID-19 Pandemic on Ischemic Stroke Patients in a Comprehensive Hospital.

PurposeThis study aimed to investigate the impact of characteristic ischemic stroke and outcomes during the first COVID-19 pandemic lockdown.Patients and MethodsA retrospective, observational cohort study of a comprehensive tertiary stroke center was conducted. Patients with ischemic stroke were divided into pre-COVID-19 lockdown (11/1/2019 to 1/30/2020) and COVID-19 lockdown (1/31/2020 to 4/30/2020) period groups. Patient data on stroke admission, thrombolysis, endovascular treatment, and 3-month routine follow-up were recorded. Data analysis was performed using SPSS according to values following a Gaussian distribution.ResultsThe pre-COVID-19 lockdown period group comprised 230 patients compared to 215 patients in the COVID-19 lockdown period group. Atrial fibrillation was more predominant in the COVID-19 lockdown period group (11.68% vs 5.65%, p=0.02) alongside patients who were currently smoking (38.8% vs 28.7%, p=0.02) and drinking alcohol (30.37% vs 20.00%, p=0.012) compared with that of the pre-COVID-19 lockdown period group. For patients receiving thrombolysis, the median door-to-CT time was longer in the COVID-19 lockdown period group (17.0 min (13.0, 24.0) vs 12.0 min (8.0, 17.3), p=0.012), median door to needle time was 48.0 minutes (35.5, 73.0) vs 43.5 minutes (38.0, 53.3), p=0.50, compared with that of the pre-COVID-19 lockdown period group. There were no differences for patients receiving mechanical thrombectomy. The median length of hospitalization (IQR) was no different. Discharge mRS scores (IQR) were higher in the COVID-19 lockdown period group (1.0 (1.0, 3.0) vs 1.0 (1.0, 2.0), p=0.022). Compared with the pre-COVID-19 lockdown period, hospitalization cost (Chinese Yuan) in the COVID-19 period group was higher (13,445.7 (11,009.7, 20,030.5) vs 10,799.2 (8692.4, 16,381.7), p=0.000). There was no difference observed in 3-month mRS scores.ConclusionPatients presenting with ischemic stroke during the COVID-19 pandemic lockdown period had longer median door-to-CT time and higher hospitalization costs. There were no significant differences in 3-month outcomes. Multidisciplinary collaboration and continuous workflow optimization may maintain stroke care during the COVID-19 pandemic lockdown.

Patterns and outcomes of stroke thrombolysis in a tertiary care hospital in North East India

Introduction: Intravenous thrombolysis with alteplase (tissue plasminogen activator -tPA) has been approved as the standard of care for the treatment of acute ischemic stroke (AIS) since 1995. Although there have been sporadic reports of hyperacute stroke thrombolysis coming from North-East India, a well-structured study from this resource poor area is lacking in this regard. Objective:To study the efficacy and safety of intravenous thrombolysis with tPA in AIS. Materials and methods: All patients of acute Ischemic stroke who were thrombolysed using the 4.5 hour window period, between Dec 2017 to April 2021 were enrolled and studied. We analyzed differences in age, gender, time from onset to start IVT, door to needle time (DNT), pretreatment NIHSS score, postoperative NIHSS score, and so on. They were followed up for a period of 3 months for the determination of outcome. The death rate at 90 days and incidence of SICH were used for assessment of safety. Results:A total of 30 patients were thrombolysed. 37% of patients were thrombolysed during the covid-19 pandemic. Hypertension was the most common risk factor. The mean Door to needle(DTN) time was 74.1 minutes with the shortest being 25 minutes. The mean NIHSS score at the point of hospitalization was 12.42 and after 24 hours was 9.27. In 57.69% of patients, the primary outcome (≥4 increment in NIHSS score) was achieved. 14.8% of patients suffered from adverse outcomes (death and SICH). Conclusion: This study re-affirms the safety and efficacy of IV tPA for hyperacute stroke thrombolysis in our set-up.

Evaluating Stroke Code Activation Pathway in Emergency Departments study

To describe the clinical characteristics and outcomes of Code Stroke activations in an ED and determine predictors of a final diagnosis of stroke or transient ischemic attack (TIA) diagnosis. This was a retrospective analysis of Code Stroke activations through an ED over 2 years at a quaternary stroke referral centre. Stroke Registry data was used to identify cases with clinical information abstracted from electronic medical records. The primary outcome was a final diagnosis of acute stroke or TIA and the secondary outcome was access to reperfusion therapies (thrombolysis and or endovascular clot retrieval). The study analysed data from 1354 Code Stroke patients in ED. Of all Code Strokes, 51% had a stroke or TIA diagnosis on discharge. Patient characteristics independently associated with increased risk of stroke were increasing age, pre-arrival notification by ambulance, elevated BP or presence of weakness or speech impairment as the initial presenting symptoms. Dizziness/vertigo/vestibular neuritis were the most common alternative diagnoses. One hundred and thirty-five patients (10%) underwent reperfusion therapy. Pre-arrival notification by ambulance was associated with higher proportion of eventual stroke/TIA diagnosis (68% vs 46%, P< 0.001) and significantly lower door to CT and door to needle times for patients undergoing thrombolysis. In a cohort of patients requiring Code Stroke activation in an ED, increased age, systolic blood pressure and weakness and speech impairment increased the risk of stroke. Prehospital notification was associated with lower door to needle times for patients undergoing thrombolysis.

Comparación entre los ictus fibrinolizados que llegaron al hospital con el servicio de emergencias 061 o por otros medios

ObjectiveAnalyze the relationship between attendance times and health outcomes of people with ischemic stroke treated with intravenous fibrinolysis, comparing those attended from the emergency units of 061 ARAGON with those arriving by other means. MethodCross-sectional, retrospective, descriptive and association study based on a consecutive series of patients treated at the Miguel Servet University Hospital in the period 2014-16, analyzing the time of care up to fibrinolysis and results of intravenous fibrinolysis, in terms of mortality and functional status at discharge. We also analyzed the influence on attendance times of the protocol change that was carried out in 2016 and that included the direct warning to neurologists, instead of the receiving emergency, as before. ResultsA total of 231 patients with stroke were collected and treated with intravenous fibrinolysis. The mean age of the patients was 75,91 (±12.48). Women accounted for 52.8% of those fibrinolysed, the average age of men being lower [74,07 (±13.71) years, compared with 77.55 (±11.07) years for women]. The mean score on the NIHS scale at admission between the two groups presented significant differences (P=0.006), being greater the affectation among those who arrived with 061 [NIHSS 13,20±6,78 vs. 10.7±6.22]. In the comparison of times between patients who arrive or not with 061, the average time to hospital was 91.42 (±59.64) vs. 93.20 (±83.73) (P=.731), without significant differences. However, there were significant differences in the time door needle (P=.046), noting that patients who are brought by 061 Aragon have better in-hospital time until fibrinolysis (better door-needle time) (67.19 (±26,03) vs. 77.83 (±38.35).In the analysis of the door needle time by years, significant differences were observed (p<0,001), being shorter each year, with a clear shortening in 2016 compared to previous ones, reflecting the impact of the update of protocols in this time period. ConclusionThe patients brought in by 061 were different (more affected), fibrinolysed in a greater percentage and faster. Direct notice to neurologists significantly shortened attendance times. In terms of mortality and functional status at discharge, there were no differences between the two groups.