For Small Institutions and Rural Care, Rapid Acquisition of Advanced Imaging May Improve Stroke Outcomes

Time-dependent criteria in duidelines for treatment of large-vessel occlusive (LVO) stroke have been established, but may be difficult to implement in small and rural institutions compared with stroke specialty centers. The Target: Stroke Phase III program suggests ways to improve timeliness of care, but these suggestions also may be difficult to implement in rural or small hospitals. In a primary stroke center, reduction of harmful delays and improved outcomes were achieved with simultaneous assessment for use of a tissue plasminogen activator (tPA) and endovascular therapy. 

In a study, presented by Kathleen Henderson, BSN, et al at the International Stroke Conference being held in Los Angeles, CA February 19-21, 2020 (ISC 2020), modified Stroke Phase III recommendations were implemented during an 8-week period. The framework for the study was the quality improvement method of plan do study act (PDSA). Stroke readiness education was provided to radiologists and emergency physicians, the latter of whom also received training in stroke screening. Stroke screening training focused on level-I stroke activations for LVOs using the Visual-Aphasia-Neglect screen. For anyone who had a positive head CT screening, head and neck CT angiography with cerebral perfusion was acquired immediately after the positive determination. 

Of 86 level-I stroke activations that presented, the proportion screened within 10 minutes improved from 55% to 81%. Arrival to determination of endovascular eligibility improved from 142 minutes at baseline (n=67) to 54 minutes (n=17). Door-to-device time improved from 194 minutes (n=7) to 111 minutes (n=1). Obtaining advanced imaging before tPA administration did not prolong door-to-needle times. 

Although this is a small single-center study, these results suggest that improvements in the timeliness of stroke treatment can be implemented in smaller settings and may improve outcomes. The simple of this screening-based protocol lends itself to extension to level-II activations and adaption at other primary stroke centers. This is notable because other research presented at ISC 2020 suggest both that use of tPA before thrombectomy has decreased and that lack of tPA use before thrombectomy has a negative effect on poststroke outcomes.