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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EStrategies to reduce delays to treatment and shorten the time to recanalization are required to improve outcomes with endovascular therapy (ET). Although procedural times are reduced with new technologies, the focus must remain on the front end of care, which consumes 75% of the time to recanalization. This article discusses MRI combined with CT for improved patient selection and outcomes, as well as lessons from the ongoing Endovascular Treatment for Small Core and Proximal Occlusion Ischemic study [ESCAPE; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01778335\u0026amp;atom=%2Fspmdc%2F14%2F1%2F20.atom\u0022\u003ENCT01778335\u003C\/a\u003E].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ENeurology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EStrategies to reduce delays to treatment and shorten the time to recanalization are required to improve outcomes with endovascular therapy (ET). Although procedural times are reduced with new technologies, the focus must remain on the front end of care, which consumes 75% of the time to recanalization, said Rishi Gupta, MD, Wellstar Kennestone Hospital, Marietta, Georgia, USA.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ETransferring stroke patients to a comprehensive stroke center (CSC) costs time. The median transfer time was 104 minutes for short distance transfers of 14.7 miles in a study of 132 patients at Rush Medical Center in Chicago, Illinois, and consumed 30% of the time in the patient care pathway [Prabhakaran S et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011]. A rapid decrement in the probability of intra-arterial treatment (IAT) of 3% per minute was found after 46 minutes had elapsed.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe time from computed tomography (CT) imaging to groin puncture (picture-to-puncture; P2P) is a positive predictive variable for outcomes. A single-center, retrospective study of P2P comparing patients who were transferred or presented at their local emergency department (ED) provided \u201ceye-opening\u201d messages said Dr. Gupta [Sun CH et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2013]. Every 90-minute increase in the time to treatment resulted in fewer patients having a good outcome (55.8% for \u0026lt;90 minutes vs 32.9% for 91 to 180 minutes). Only 29% of the transferred patients achieved an mRS score of 0 to 2, compared with 51% of patients with local ED admission because of the longer door-to-puncture (D2P) times of 300 versus 177 minutes.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003ETwo strategies to reduce treatment delay are physician transfer to the non-CSC and improving prehospital triage. A study in Shanghai, China, showed transferring the physician, compared with transferring the patient, reduced door-to-balloon time by nearly 50 minutes (92 vs 141 minutes) and increased the proportion of patients treated in \u0026lt;90 minutes (36% vs 13%, respectively) [Zhang Q et al. \u003Cem\u003ECirc Cardiovasc Qual Outcomes\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EEfforts to improve prehospital triage include using the Los Angeles Motor Scale (LAMS) to quantify the degree of weakness, which has an 85% accuracy for detecting large vessel occlusion [Nazliel B et al. \u003Cem\u003EStroke\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe protocol at Wellstar Kennestone Hospital includes using the LAMS and instructing emergency medical services (EMS) to take patients with symptoms of stroke plus hemiplegia directly to the CSC if travel time is \u0026lt;30 minutes.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMRI COMBINED WITH CT IMPROVED PATIENT SELECTION AND OUTCOMES\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe value of noncontrast CT to rapidly rule out hemorrhage in patients presenting with a stroke so intravenous tissue plasminogen activator (t-PA) can be administered is accepted. Other imaging strategies are being investigated to improve patient selection for acute ET, including CT angiography (CTA) to determine large vessel occlusion and evaluate collaterals, CT perfusion, and magnetic resonance imaging (MRI). However, there are conflicting data on their benefit and currently there is no accepted standard for advanced imaging.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThe Cleveland Clinic converted from a CT-based to an MRI-based imaging protocol in April 2010 to improve decision-making in patients presenting with a stroke. The hyperacute (HA-MRI) protocol, added to CT and CTA, resulted from intensive planning, testing and quality control, even determining the fastest path through the hospital and elevators to ensure rapid completion, said Muhammad Shazam Hussain, MD, Cleveland Clinic, Cleveland, Ohio, USA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe addition of pretreatment MRI to CT and CTA, compared with CT and CTA alone, improved 30- and 90-day mRS scores in patients with large vessel occlusion (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E), according to results of their retrospective study to evaluate the benefit of the new protocol [Wisco D et al. \u003Cem\u003EStroke\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/20\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022mRS Score Outcomes by Imaging Protocol\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1292493156\u0022 data-figure-caption=\u0022mRS Score Outcomes by Imaging Protocol\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/20\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/20\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/1\/20\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14287\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EmRS Score Outcomes by Imaging Protocol\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EHyperacute=pretreatment magnetic resonance imaging protocol; mRS=modified Rankin Scale score; prehyperacute=computed tomography and computed tomography angiography protocol.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Wisco D et al. Addition of hyperacute MRI AIDS in patient selection, decreasing the use of endovascular stroke therapy. \u003Cem\u003EStroke\u003C\/em\u003E 2014;45(2):467\u2013472. With permission from Lippincott Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EOf 179 HA-MRI patients, 34.1% had atrial fibrillation at baseline, compared with 48.7% of the 88 prehyperacute patients. The patients were 70 years old, 56% were women, and the NIHSS was 15.8 to 16.4 at baseline.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ENo significant difference was found in the time to ET with HA-MRI (390 vs 407 minutes prehyperacute), suggesting it was possible to insert HA-MRI without significant time delay, said Dr. Hussain.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe proportion of patients who had an ET was reduced to 51.7% with HA-MRI from 96.6% (p\u0026lt;0.01), mainly because large infarctions not seen on CT were seen on MRI. In the HA-MRI group, compared with the prehyperacute group, more patients achieved a mRS score of 0 to 2 at 30 days (23.6% vs 9.1%; p=0.01) and fewer died (33.1% vs 45.5%; p=0.09).\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe probability of clinical outcomes in all patients and in those who had ET is shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E. Age, baseline NIHSS, and pretreatment MRI were significantly associated with improved outcomes on multivariable analysis (p\u0026lt;0.05). The daily direct costs were reduced by 24.5% with HA-MRI compared with CT and CTA (95% CI, 14.1% to 33.7%; p\u0026lt;0.0001).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/14290\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/14290\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14290\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-16\u0022 class=\u0022first-child\u0022\u003EProbability of Clinical Outcomes in Cleveland Clinic Study With Pretreatment MRI\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ELESSONS FROM ESCAPE: TEAM WORK AND PROTOCOLS IMPROVING TIME TO RECANALIZATION\u003C\/h2\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EPreliminary data from the ongoing Endovascular Treatment for Small Core and Proximal Occlusion Ischemic study [ESCAPE; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01778335\u0026amp;atom=%2Fspmdc%2F14%2F1%2F20.atom\u0022\u003ENCT01778335\u003C\/a\u003E] suggest that an imaging-to-recanalization time of \u0026lt;90 minutes was achieved in \u223c80% of endovascular patients, who received thrombectomy or thrombolysis. Mayank Goyal, MD, University of Calgary Calgary, Alberta, Canada, said the study is examining whether or not a patient with an acute ischemic stroke should go to the catheterization laboratory, not whether ET is superior to t-PA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EThe key to achieving these results is having two teams parallel process patient care. The stroke team is responsible for clinical items, including trial checklist, blood work, informed consent, moving the patient, and assessing need for anesthesia. Simultaneously, based on data only from the CTA, the interventionalist plans and prepares for the procedure. Notably, Prof. Goyal stressed the need for Bayesian thinking, that is, not relying on a singular piece of information, but putting together all key pieces of available information for decision-making. This is a particular focus for training to further improve the proportion of patients achieving the \u0026lt;90-minute benchmark.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EAt his institution, Prof. Goyal is informed as soon as a patient is randomized to ET and he is scrubbed with needle in hand when the patient arrives. To prevent wastage, equipment is standardized in case the patient is randomized to a conservative approach, and expensive items are not opened until time of use. He recommends the time immediately after the procedure be used to clean and organize and plan what to do next if the vessel is not open. Using parallel processing, his institution achieved in one example case times to recanalization from the door of 50 minutes, from CT 42 minutes, from clot recognition 5 minutes, and from puncture 8 minutes.\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EClear plans must be established for the prehospital and ED phases, as well as for each type of procedure. Clear protocols for angiography must be established to receive stroke patients 24\/7, including preparing in advance stroke trays with a basic set of items and training staff.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EA critical issue that produces delays is obtaining informed consent, which took an average of 30 minutes in the IMS-III trial, and affects only the endovascular arm of the trial, Prof. Goyal stated. To obtain efficient and fast consent, he recommends training staff and preparing an institutional response to the main questions asked at the time of informed consent.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/1\/20.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzpdkp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzpdkp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzpdkp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}