Objective: Pre-hospital, in-hospital, and patient factors are associated with variation in door to needle (DTN) time in acute ischemic stroke (AIS). Publications are usually from large single centers or multicenter registries with less reporting on national results. Materials and methods: All AIS patients treated with intravenous tissue plasminogen activator (iv-tPA) over 4 years (2013–2016) in Northern Ireland were recorded prospectively, including patient demographics, pre-hospital care, thrombolysis rate, and DTN time. Logistic regression was performed to identify factors associated with DTN time. Results: One thousand two hundred and one patients from 10,556 stroke admissions (11.4%) were treated with iv-tPA. Median NIHSS was 10 (IQR 6-17). Median DTN time was 54 min (IQR 36-77) with 61% treated < 60 min from arrival at hospital. National thrombolysis numbers increased over time with improving DTN time ( P = 0.002). Arrival method at hospital (ambulance OR 2.3 CI1.4-3.8) pre-alert from ambulance (pre-alert OR = 5.3 CI3.5-8.1) and time of day (out of hours, n = 650, OR 0.20 CI 0.22-0.38) all P < 0.001, were the independent factors in determining DTN time. Variation in DTN time between centers occurred but was unrelated to volume of stroke admissions. Conclusion: Ambulance transport with pre-hospital notification and time of day are associated with shorter DTN time on a national level. Most thrombolysis was delivered outside of normal working hours but these patients are more likely to experience treatment delays. Re-organization of stroke services at a whole system level with emphasis on pre-hospital care and design of stroke teams are required to improve quality and equitable care in AIS nationally.

BackgroundNeuroimaging helps clinicians make accurate diagnoses. Most stroke patients have their imaging reported by general radiologists.MethodsAs part of a quality assurance program a database for neurological patients with second opinion reporting from neuroradiologists was searched from 2008 to 2016 to identify patients in whom stroke lesions were missed at initial reporting by general radiologists. Patient demographics, scanning modality, stroke type, location and laterality were recorded.Results36 patients, 18 men, 18 women, mean age 59.0 (SD 13.8) years were identified in whom a stroke lesion was not detected on initial reporting. The lesions included cerebellar infarcts in 14 patients (bilateral in 3), pontine ischaemia/infarction (n=6), supratentorial infarction (n=9), vessel abnormality (n=6 – dense middle cerebral and basilar arteries, dissection and cerebral venous sinus thrombosis), and spinal infarction (n=1). In 9 (24%) patients the missed lesions occurred solely on CT brain scanning. The missed lesions were acute presentations in 8 (22%) patients.ConclusionStroke lesions can be missed with both CT and MRI. The posterior fossa and dense artery signals (middle cerebral artery and basilar artery) are prone to detection errors.