Background and Purpose —Rapid transport of patients to specialized centers is widely used in the management of myocardial infarction, trauma, and more recently, acute stroke. We evaluated the role of helicopter transportation as it relates to the availability of acute stroke therapies and patients’ perceptions of care. Methods —We reviewed records of all patients transferred to a university hospital within 24 hours of stroke onset from January 1996 to December 1997. Data were collected on demographics, neurological deficit, treatment, and outcome. In addition, a questionnaire was sent to all patients with items about perceived reasons for helicopter transfer, expected and actual treatment, outcome, and overall impression. Results —Helicopter transfer was used for 73 stroke patients. Before transfer, 8 patients (11%) received tissue plasminogen activator (tPA). On arrival, no patient received tPA, 38 patients (52%) were enrolled in acute stroke studies, and 35 patients (48%) received no specific medication. All but 2 patients were managed in a specialized stroke unit. Of the 35 patients who received no specific therapy, 24 (69%) were ineligible for treatment or study enrollment owing to 1 or more exclusion criteria, but rarely (3%) because of time. Of the 45 respondents to the survey, most (84%) were transferred at the suggestion of the physician at the originating hospital because of a possible treatment that was unavailable there. Most patients (93%) believed that there was a benefit from emergent helicopter transfer to a stroke center, although 40% of respondents received no specific therapy. Conclusions —Interhospital transfer by air may benefit a substantial number of acute stroke patients by offering potential therapies and intensive management not available elsewhere.

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P192 Background: One strategy that has been advocated to increase the percentage of stroke patients treated with thrombolytic therapy is the establishment of primary stroke centers in community hospitals. Methods: A stroke center was established at a 397-bed private community hospital in Bethesda, Maryland consistent with published recommendations (M. Alberts, et al, JAMA. 2000;283:3102). Following a 4 month pilot phase during which the stroke critical care pathway was introduced into hospital practice, around the clock coverage by the on-call stroke team was initiated on January 3, 2000. According to the pathway, the team was to be paged for any patient identified with a suspected new stroke and persistent deficits of less than 6 hours in duration (initial screening criteria). Observations of patient characteristics and times of key points in acute management are reported through July, 2000. Results: Sixty-four patients met the initial screening criteria (58 of these patients arrived at the hospital within 3 hours of onset of symptoms). Time in minutes to action (patient arrival at hospital to paging of neurologist, to arrival of neurologist, to scan) decreased over the first 7 months of stroke coverage (24 to 12, 28 to 16, 52 to 32, respectively, per 2-month average). Of 143 patients hospitalized with ischemic stroke during this period, 15 patients (10%) were treated with t-PA (10 IV, 5 IA). For the IV-treated patients, the median time to treat was 130 minutes and median door to needle time was 83 minutes, in line with benchmark values. During the same 7-month period of the year prior to the center initiation, only 3 patients were treated with t-PA at this hospital. Conclusions: A 5-fold increase in t-PA usage was observed in the first 7 months following the establishment of the stroke center (3-fold increase for IV t-PA use only). Establishment of a stroke center at a community hospital is feasible. Our experience to date suggests that a substantial increase in the frequency of patients receiving t-PA therapy for ischemic stroke may be achievable shortly after initiation of a community hospital stroke center.

P177 Background: Acute MRI imaging including diffusion, perfusion, angiography, and FLAIR provides useful information in the diagnosis of stroke. It has been proposed that the stroke MRI exam may improve patient selection and outcome for tPA therapy. An alternate view holds that MRI may excessively delay times to treatment and lead to worse outcomes. To look for any evidence of adverse effects of MRI screening, we examined our initial experience using MRI as a screening exam for tPA therapy. Methods: The critical care pathway for stroke at our hospital mandates both CT and MRI for all patients under consideration for IV tPA therapy within 3 hours of onset. Delays are minimized by 24 hour in-house MRI technologists and immediate availability of both the MRI and CT scanners when a stroke code is called. Scans are monitored by a stroke neurologist and/or radiologist to minimize delays in image interpretation. MRI exclusion criteria for tPA are: (1) presence of subacute lesions not suspected from history or CT (2) normal DWI, PWI and MRA of good technical quality (3) any evidence of hemorrhage. Results: Twelve patients were treated with tPA; 4 were excluded based on MRI Results: 2 had subacute lesions, 1 had evidence of chronic hemorrhage, 1 had a normal MRI (final diagnosis: Guillain-Barre Syndrome). Four of the treated patients had no MRI because of contraindications (n=3) or scanner unavailability (n=1). One patient was treated based on MRI results only; CT was unavailable. Median door-to-needle time (MDTNT) for the 8 MRI screened patients was 83 minutes; median time-to-treatment (MTTT) was 134 minutes. Four of these 8 patients achieved a modified Rankin Score of 0 or 1 (mRS12) on follow-up. One had a symptomatic hemorrhage and died (time-to-treatment was 116 minutes). Conclusion: In this small series, door to needle times and outcomes are well within benchmark values (STARS Study: MDTNT - 96 minutes, MTTT - 164 minutes, mRS12 at outcome - 43%; G. Albers, et al, JAMA. 2000;283:1145). There is no evidence to date that MRI screening for iv tPA leads to excessive delays or worse outcomes. A larger series is necessary to demonstrate the safety and efficacy of MRI screening for IV thrombolysis.