Exploratory Analysis Of Time Delays In Administrating
Endovascular Therapy For Acute Ischemic Stroke
Amit Kansara MD, Ambooj Tiwari MD, Paritosh Pandey MD, Sandra Narayanan MD, Andrew Xavier MD
Wayne State University/ Detroit Medical center, Detroit
Disclosure
None
Objective
To study time delays in administrating endovascular therapy in acute ischemic stroke
Background
There is very limited published data on time delays associated with the provision of endovascular therapy in acute ischemic stroke.
Scientific statements about IA therapy and mechanical interventions set the maximum number of hours from symptom onset
There is no guideline or statement regarding actual door to needle or door to balloon time for neurovascular rescue.
Cardiac intervention timeline
Methods Retrospectively- records of patients presenting with
acute ischemic stroke within 8 hours of symptom onset who underwent endovascular procedure at our institution were reviewed.
Following data were collected - NIHSS - symptom onset time - time of ER presentation - time of CT - incision time at the start of procedure - time of micro-catheter placement - time of recanalization
- recanalization outcome
Results
43 patients (23 men, mean age 65.2 + 14.6) Median NIHSS 17 Symptom onset to ER presentation time
142.9 + 89 minutes. For the 24 patients presenting directly to our
center, the time from presentation to CT scan was 16.9 + 8.1 minutes
Time interval from CT scan to incision
121.9 + 69.2 minutes
Symptom onset to incision time
- 269.5 + 110.3 min in pts presenting to our center
- 297.1 + 59.9 min in transferred patients (p=0.33)
IV thrombolysis was administered in 10 patients prior to intervention
Persistent large vessel occlusions were identified in 35 patients:
- 20 MCA, - 9 Carotid T, - 8 extracranial ICA, - 3 Vertebrobasilar - 5 tandem occlusions
Multi modality reperfusion therapy used IA tPA – 21MERCI – 22Penumbra – 13Angioplasty – 12Stenting – 11
Incision to micro catheter time 33 + 20.6 min
Recanalization (TIMI 2 or 3) 23 patients (66%)
Micro catheter to recanalization time 44.7+ 29.7 min
Three patients (8.5%) had symptomatic ICH. Overall mortality rate was 30.2 % Discharge MRS <3 noted in 41.9% of patients.
Discussion
For intravenous thrombolysis - 60 min is recommended( from admission, includes evaluation by stroke team, history, iv line placement, foley catheter placement, CT scan and read)
Our Timeline
Timeline
0 50 100 150 200 250 300 350 400
Onset to ER
Door to CT
CT to stick
Stick to MC
MC to recan
ER to CT CT to incision incision to MC MC to recanalization0
20
40
60
80
100
120
140
Time after ER presentation
Min
ute
s
AcuteIschemicstroke
Indication Recommendation Class and level of evidence
IA TPA
Less than 6 hours and ineligible for IV TPA
Reasonable to consider intra-arterial thrombolysis in selected patients
Class I, LOE B
MechanicalDisruption
Less than 8 hours and ineligible for or failing IV TPA
May be reasonable to perform mechanical disruption to restore cerebral blood flow in selected patients
Class IIb, LOE B
Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures
Circulation. 2009;119:2235-2249
Stroke Centers Community hospitals – ER evaluation, stroke
pager activation, staff with stroke neurologist and then decision about the transfer for further intervention
At tertiary care center – after ER evaluation, Evaluation of patients by on call resident/stroke fellow, staff with stroke attending and decision about the endovascular intervention
or simultaneous activation of stroke pager for
stroke service and neurointervention service
A Multicenter Analysis of "Time to Microcatheter" for Endovascular Therapy in Acute Ischemic StrokeJournal of Neuroimaging Jefferson T. Miley, Muhammad Zeeshan Memon, Haitham M. Hussein, Douglas A. Valenta, M. Fareed K. Suri, Gabriela Vazquez, Adnan I. Qureshi
CT scan to microcatheter ("time to microcatheter") 91 174 ± 60 173 (66-319)
"Time to microcatheter" Institution A 48 167 ± 55 167 (71-319)
"Time to microcatheter" Institution B 14 218 ± 69 222 (93-316)
"Time to microcatheter" Institution C 29 164 ± 57 174 (66-302)
Our Timeline
Minnesota "A"
Minnesota "B"
0 50 100 150 200 250
CT to MC
MC to recan
Author, Year
Definition of Time Interval
Number of Patients
Age (Mean)
NIHSS (Median)
Time Interval in Minutes (Mean)
Wolfe et al. 2008
Onset to treatment 55 68.1 15 261
Poncyljusz et al. 2007
Onset to start of treatment
16* 54.2 16 330
Onset to start of treatment
16† 57.5 16 306
Ogawa et al.2007
Onset to intraarterial urokinase infusion
56 66.9 14 227
Shaltoni et al.2007
Symptom onset to intraarterial bolus
69 59.8 18 285
Mattle et al.2008
Onset to intraarterial treatment
55 61 17‡ 244
Kim et al. 2008
Onset to localized intraarterial thrombolysis
19 65.4 17 312
A Multicenter Analysis of "Time to Microcatheter" for Endovascular Therapy in Acute Ischemic StrokeJournal of Neuroimaging Jefferson T. Miley, Muhammad Zeeshan Memon, Haitham M. Hussein, Douglas A. Valenta, M. Fareed K. Suri, Gabriela Vazquez, Adnan I. Qureshi
Possible reasons for time delay
Decision making Need for further imaging Lack of universal established hospital guideline
of activating neuroendovascular service Lack of ER alertness in pushing patient for
intervention in time pressured manner like cardiac patient
Limitations
Retrospective dataSmall number of patientsRecall bias
Conclusion
Factors causing delays in administering endovascular stroke treatment can be identified and could potentially help in reducing the time to recanalization.
Thank you !
