“Picture to Puncture”

Abstract

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P <0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P <0.001) and significantly worse clinical outcomes (29% versus 51%; P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Predictive Value of Modifications of the Prehospital Rapid Arterial Occlusion Evaluation Scale for Large Vessel Occlusion in Patients with Acute Stroke

“…The RACE scale score was not detailed item-by-item in 16 cases and therefore we studied 341 patients (53.4% men; age (mean±SD) 70±13 years; NIHSS score at admission (median [interquartile range] 8 [3][4][5][6][7][8][9][10][11][12][13][14][15][16] had 85% sensitivity, 68% specificity and correctly classified 71% patients. The RACE and NIHSS scores were strongly correlated (r=0.78; p<0.001).…”

“…However, benefit declines with increasing time after symptom onset (6).Transferring patients from a Primary Stroke Center (PSC) to a Comprehensive Stroke Center (CSC) commonly delays endovascular treatment (7). A pre-hospital clinical tool to detect LVO patients and facilitate rapid transport directly to a CSC is therefore of crucial importance.…”

Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

“…A prespecified efficiency target for the time from noncontrast CT to reperfusion encouraged fast image acquisition and interpretation and fast decision making. 16,[34][35][36][37] Critical to the achievement of rapid treatment was parallel decision making and action. For example, participants in the intervention group underwent groin puncture while alteplase was being infused, and complete reperfusion was achieved in some participants before the alteplase infusion was finished.…”

“…The primary emphasis was on achieving early reperfusion. 15,16,34,35 Imaging-related selection criteria focused on the population with a small infarct core at baseline, which was defined by both modest early ischemic change on noncontrast CT and moderate-to-good collateral circulation distal to the occlusion. 26 A new technique of collateral assessment, multiphase CTA, was used in a majority of patients (Fig.…”

Addition of Hyperacute MRI Aids in Patient Selection, Decreasing the Use of Endovascular Stroke Therapy

“…In this latter time window, the chance of good outcome from unselected populations has been shown to be low, 21 and patient selection with imaging may be more important. In addition, it has been shown by Sun et al 22 that patients transferred from another facility introduces significant delay in patient treatment and this is associated with decreased chances of good clinical outcome. This presents an opportunity for process improvement to decrease time delays by developing an acute stroke screening and transfer protocols for patients who may be a candidate for EST.…”