Purposeof review: Tenecteplase has been studied and recommended as an alternative thrombolytic agent in acute stroke patients. A brief review of clinical trials and guidelines pertinent to our clinical decision algorithm is described. This is followed by operational steps that were made to create and implement a clinical pathway based on available evidence in which tenecteplase is used in select stroke patients at our comprehensive stroke center.Recent findings:A number of patients have been treated at our center with IV tenecteplase. A case is presented to illustrate the successful implementation of this new process.Summary:Development of our protocol is discussed in detail in order to enable other centers to create their own clinical pathways for thrombolytic treatment of acute ischemic stroke using tenecteplase.

Background: Thin-sliced reformatted non-contrast CT head are not widely used to detect the thrombus. The purpose of this study was to investigate whether thin-sliced reformatted non-contrast CT scans could be reliably used to detect and measure size of the thrombus size in patients with acute ischemic stroke due to LVO and therefore serve as a potential substitute of CT Angiogram (CTA). Success of this paradigm could reduce stroke decision algorithm to nonenhanced CT scan before a code neurointervention is activated; hence saving time and contrast. Methods: Comprehensive prospective analysis of patients who underwent acute endovascular intervention for LVOs at a community based, university affiliated comprehensive stroke center during one year period (Jan 2015-Dec 2015) was done. The raw data of non-enhanced CT scans and CTAs were collected. All raw data were reconstructed with thin slices of 0.625 mm using standard GE software. Two observers independently evaluated the 5-mm maximum intensity projections of the thin slices and CTA in coronal and axial projections for best assessment of vessel diameter and thrombus length. Inter-observer agreement was measured using Cohen κ. Results: There were 749 patients who presented with acute ischemic stroke during the specified time period. Of those 67 were large vessel circulation strokes; of which, 22 had both CT and CTA done. Mean clot length measured was 14.75 (SD +/-4.95) on thin slices CT and 15.02 (SD +/-5.47) on CTA. Vessel diameter measured was 2.77 (SD +/-0.47) on thin sliced reformatted CT and 2.41 (SD +/-0.49) on CTA. There were no instances where clot size or vessel diameter could not be measured on thin slice reformatted CT. Inter-observer agreement was higher for both CTA (κ, 0.83) versus thin-slice nonenhanced CT reconstructions (κ, 0.80). Conclusions: Thin-sliced reconstructions of standard cranial nonenhanced CT raw data can be reliably used to detect and measure the thrombus size in LVOs. It also reliably measures the vessel diameter, making intervention planning possible. Larger multicenter trials are needed to validate our data.

Background: Comprehensive stroke centers (CSC) provide around the clock complex services when compared primary stroke centers (PSC) for acute ischemic stroke patients. As most stroke treatments are time-sensitive, a delay in admitting these patients due to transfer from PSC can cause an increased degree of dependence and disability and poorer outcomes. This is due to CSC’s having more robust availability of intravenous, intra-arterial, and endovascular revascularization therapies. We propose that patients that are transferred to a CSC from PSC have increased onset to puncture times and are more likely to have a larger degree of disability compared to those who are directly admitted to comprehensive stroke centers. Methods: Patients were evaluated over a 30-month period from January 2016- July 2018 using retrospective data from a university affiliated community based comprehensive stroke center. The time of onset of symptoms were recorded as well as the puncture times for stroke thrombectomy patients. Patients were separated by arrival mode and times were analyzed using average calculations. Modified Rankin Scores for all of the patients were collected using existing registry data and follow up visits. GraphPad Quick Calcs Web site was used to obtain descriptive statistics and intergroup differences. Results: A total of 1,412 ischemic stroke patients from January 2016 to July 2018 were studied. The patients that were transferred from other facilities (n=70) took longer to initiate acute interventional treatment than those that arrived via EMS from the field (n=156); 474 minutes vs 389 minutes respectively; from the onset of symptoms to recanalization (a delay of more than an hour). The patients that were transferred from other facilities had a median mRS score of 3, while the patients that arrived by EMS from the field had a median MRS score of 1 at 90 days. The multivariate analysis performed took into account the risk factors and initial clinical severity. The 90 days’ outcome were statistically significantly different (p<0.01). Conclusion: Patients that arrive to the CSC via EMS are promptly triaged and treated sooner than those that arrive to PSC’s prior to being transferred to CSC’s. This loss of time results in a statistically significant poorer outcome.

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Background: Various strategies have been implemented to reduce acute stroke treatment times. A unique code process pathway was designed at our hospital specifically to be activated by the stroke team for the purpose of rapidly assembling the Neurointerventional team. Methods: Code Neurointervention (NI), was designed and tested from January 2014 to April 2014 for all the patients who presented with ischemic strokes to our community based, university affiliated comprehensive stroke center. We retrospectively analyzed all patients who had Code NI called from May 1, 2014 to April 30, 2015 and compared them to patients who underwent acute endovascular treatment the prior year (Non Code NI). The following parameters were compared: decision to recanalization and door to recanalization times. Further analysis was done to compare patients presenting during business hours (Monday-Friday 8am-5pm) and off hours using GraphPad QuickCalcs Web site. Results: There were 28 Code NI; 14 were called during work hours and 14 during off hours. The previous year 25 patients underwent acute endovascular intervention; 12 during work hours and 13 during off hours. Mean decision to recanalization time was 106 (Code NI) vs 115 minutes (Non Code NI) (p<0.0.6) during work hours and 154 (Code NI) vs 139 minutes (Non Code NI) (p<0.37) during off hours. Mean door to recanalization time was 169 (Code NI) vs 173 minutes (Non Code NI) (p<0.85) during work hours and 252 (Code NI) vs 243minutes (Non Code NI) (p< 0.75) during off hours. Subset analysis of time parameters for patients in Code NI group showed mean decision to recanalization times of 106 minutes during work hours vs 154 minutes off work hours (p<0.004). Mean door to recanalization times were 169 minutes vs 251 minutes (p<0.0003), respectively. Conclusion: Institution of Code NI significantly improved intervention time parameters during work hours as compared to off hours. Rapid assembly of the neurointervention team, rapid availability of imaging and angiography suite likely contribute to these differences. Further initiatives, such as improving neurointervention staff availability during off hours or cross training other staff can further improve acute intervention time parameters.