Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience.

BACKGROUND: Current American Stroke Association guidelines recommend initiating intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) within 60min of patient arrival, given the benefits of IVT for AIS are time dependent. This study aimed to identify the delaying factors in door-to-needle time (DTN) in the emergency department of one of the largest comprehensive stroke centers in New York State. We also recommended measures to reduce the delays. METHODS: We retrospectively reviewed the medical charts of all AIS patients who received IVT in our emergency department patients between April 1, 2012 and December 31, 2015 to identify those with a DTN time of >60min. We categorized the factors causing the delay into different groups. For each group, we recommended measures to reduce the treatment delays. RESULTS: A total of 487 patients received IVT for AIS during the 3.7-year period. Of these, 96 patients (20.4%) met our DTN time delay criteria. Delays for obtaining stroke imaging and hypertension control were the most common factors. Thirty eight patients (39.5%) had delay in obtaining CT-based stroke imaging. Twenty-two patients (22.9%) required control of elevated blood pressure prior to IVT. Other causes for delay in DTN time included delay in stroke triage and paging (11.4%), fluctuating neurological symptoms (7.2%), uncertainty about diagnosis (12.5%), delays associated with obtaining consent (9.3%), and uncertainty about the time of symptom onset (5.2%). CONCLUSION: Important and common causes of delay in IVT for AIS were identified in a review of charts at our comprehensive stroke center. The authors recommend strategies to achieve faster DTN time for each of the delaying factor categories including faster acquisition and interpretation of stroke imaging, more effective triage protocols and faster blood pressure control for AIS patients who are eligible for IVT.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with Thrombocytopenia.

OBJECTIVE: To determine the safety of intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) who had a platelet count <100,000 /mm3. METHODS: We reviewed the charts of all patients who received IV rtPA for AIS during a 9.6-year period at our stroke center. Those with platelets <100,000/mm3 were identified. Head computed tomography scans performed in 24-36 hours postthrombolysis were reviewed to evaluate the rate of symptomatic intracranial hemorrhage (sICH). RESULTS: A total of 835 patients received IV rtPA for AIS during this period. A total of 5 patients were identified to have a platelet count <100,000/mm3. One of them (20%) developed sICH post-IV tPA administration .The mean platelet count of those 5 patients was 63,000 ± 19,000/mm3. To the best of our knowledge, only 21 thrombocytopenic patients have been reported to receive IV rtPA for AIS in the medical literature. Combining our 5 cases with 21 patients previously reported, we have 26 AIS patients who had a platelet count <100,000/mm3 and received IV rtPA, with 2 of them developing sICH (7.7 %). Comparing the rate of sICH among this group with the patients with normal platelet count in our cohort, there was no statistically significant difference (7.7% versus 6.04%, P value = .73). CONCLUSION: IV rtPA for AIS might be safe in patients with platelet count <100,000/mm3 and it is reasonable not to delay IV rtPA administration while waiting for the platelet count result, unless there is strong suspicion for abnormal platelet count.