Stroke Prenotification Is Associated with Shorter Treatment Times for Warfarin-Associated Intracerebral Hemorrhage

Abstract

Background: Warfarin-associated intracerebral hemorrhage (WAICH) is a devastating disease with increasing incidence. In this setting, treatment with prothrombin complex concentrates (PCC) is essential to correct coagulopathy. Yet despite the availability of coagulopathy correction strategies, significant treatment delays can occur in emergency departments (EDs), which may be overcome using stroke prenotification strategies. To explore this, we compared arrival-to-treatment times with PCC for WAICH between two different stroke response systems that used the same international normalized ratio (INR) correction protocol. Methods: We established a registry of consecutive patients presenting with WAICH and treated with PCC presenting to two Canadian tertiary-care academic stroke centers: one with a stroke prenotification system, and one with a traditional ED assessment, treatment and referral system. In this comparative cohort design, we defined the WAICH diagnosis time as the earliest time point where both INR and CT were available. We compared median times from arrival to treatment, as well as arrival to diagnosis, and diagnosis to treatment. Results: Between 2008 and 2010, we collected data from 123 consecutive patients with intracranial hemorrhage who received PCC for INR correction (79 from ED referral, and 44 prenotification). Onset-to-arrival times, demographics, Glasgow Coma Scale scores, and baseline INR were similar between the two systems. Arrival-to-treatment times were significantly shorter in the prenotification system as compared to the traditional ED referral system (135 vs. 267 min; p = 0.001), which was driven by both decreased arrival-to-diagnosis time (49 vs. 117 min; p = 0.006), as well as decreased diagnosis-to-treatment time (56 vs. 112 min; p < 0.001). Arrival-to-scan times and arrival-to-INR times were similarly shorter in the prenotification system (68 vs. 118 min and 20.5 vs. 47 min, respectively). Conclusion: Stroke prenotification was associated with shorter arrival-to-treatment times for emergent INR correction in patients with WAICH, which was driven by both faster diagnosis and treatment. Our results are consistent with those seen in ischemic stroke, suggesting that prenotification systems present an opportunity to optimize acute intracerebral hemorrhage therapy.

Acute stroke alert activation, emergency service use, and reperfusion therapy in Sweden

“…We found socioeconomic factors to be independently associated with the frequency of stroke alerts, and having a low level of education reduced the odds of stroke alert by 5%, stroke, diabetes, and being dependent in ADL before the index stroke or unconscious on arrival at the hospital. Because stroke alerts are associated with shorter time from admission to diagnosis and reversal of anticoagulation in warfarin-associated intracerebral hemorrhage (Dowlatshahi et al, 2013), it is worth noting that patients who were diagnosed with an intracerebral hemorrhage were more likely than average to have a stroke alert.…”

“…Stroke alerts (prenotification by ambulance staff members or initiated in the emergency department) have been shown to be strongly associated with shorter in-hospital delay to the onset of treatment (door-toneedle time [DNT]) and higher proportions of patients being treated with thrombolysis (Binning et al, 2014;Lin et al, 2012a;McKinney et al, 2013;Patel, Rose, O'Brien, & Rosamond, 2011;Prabhakaran, O'Neill, Stein-Spencer, Walter, & Alberts, 2013;Ragoschke-Schumm et al, 2014). Additional benefits of prenotification have been reported in patients with warfarin-associated intracerebral hemorrhage, in whom the time to reversal of anticoagulation was shortened (Dowlatshahi et al, 2013). Rapid triage and immediate stroke team activation (stroke alert) are important components of Target: Stroke, which is a nationwide quality-improvement initiative of the American Heart Association and the American Stroke Association to improve the care of stroke in the US (Fonarow et al, 2011(Fonarow et al, , 2014, and they are recommended in the guidelines issued by the European Stroke Organisation (2008).…”

Prehospital Reversal of Warfarin-Related Coagulopathy in Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit

“…A prior report on shortening the time to warfarin reversal by stroke team prenotification from the field reported median door-to-needle time of 135 minutes. 12 In a hemorrhage registry, the shortest time from onset to therapy was 1 hour, but the median was 15 hours among 64 patients. 13 In the largest series of mobile stroke unit deployments from Berlin, of 1455 patients evaluated, 559 (38.4%) had acute ischemic stroke and 177 (12.2%) were treated with thrombolysis in MSTU.…”

Frequency, Predictors, and Outcomes of Prehospital and Early Postarrival Neurological Deterioration in Acute Stroke

“…Many interventions for treatment of acute stroke are most effective when initiated as soon as possible after stroke onset . As a result, both delivery of standard treatments and research studies of experimental treatments are increasingly migrating to the early postarrival ED time period or directly to the prehospital phase of care . The earliest point from which neurological deterioration can be systematically studied is the initial assessment by emergency medical services personnel prior to transport.…”