Minimising time to treatment: targeted strategies to minimise time to thrombolysis for acute ischaemic stroke.

Time to thrombolysis is a critical determinant of favourable outcomes in acute ischaemic stroke. It is not infrequent that patient outcomes are compromised due to out-of-hospital and in-hospital time delays. On the other hand, time delays could be minimised through the identification of barriers and the implementation of targeted solutions. This review outlines the different strategies in minimising treatment delays and offers recommendations. Literature search in PubMed, Medline and EBSCO Host was conducted to identify studies that are relevant to reduction of time to treatment from January 1995 to December 2012. Strategies to reduce time to thrombolysis are categorised into pre-hospital strategies, in-hospital strategies and post-treatment decision strategies. Proposed pre-hospital strategies include public education on stroke symptoms awareness, prioritising stroke by emergency medical services, increasing ease of access to medical records, pre-hospital notification, and mobile computed tomography scanning. In-hospital strategies include a streamlined code stroke system, computed tomography scanner co-location with emergency department, 24/7 availability of stroke physicians, point-of-care laboratory testing and access to expert neuroimaging interpretation. Post-decision strategies include increasing availability of intravenous thrombolysis and simplification of informed consent procurement. Time to thrombolysis delays is multifactorial. Effective reduction of time delays for acute ischaemic stroke requires the correct identification of and targeted strategies to overcome time barriers.

Does a 'code stroke' rapid access protocol decrease door-to-needle time for thrombolysis?

BACKGROUND: Timely administration of intravenous tissue plasminogen activator (IVtPA) for acute ischaemic stroke is associated with better clinical outcomes. Therefore, a coordinated hospital system of acute clinical assessment and neuroimaging will likely avoid delays in IV-tPA administration. AIM: In July 2007, we implemented a 'code stroke' rapid access protocol at the Royal Melbourne Hospital with the aim of achieving rapid stroke assessment and treatment. This study investigates the quality of our 'code stroke' protocol and its impact on door-to-needle time and IV-tPA usage. METHODS: We included patients thrombolysed with IV-tPA from January 2003 to June 2007 (pre-code stroke era) and patients thrombolysed from July 2007 to December 2010 (code stroke era). Data collected were demographics, time points (stroke symptom onset, presentation to emergency department, neuroimaging and thrombolysis) and clinical outcomes (modified Rankin Scale) at discharge, symptomatic, intracerebral haemorrhage and death during admission). We compared the door-to-needle time and usage of IV-tPA between the two eras. RESULTS: Patient data on 98 'pre-code stroke' thrombolysed patients and 189 'code stroke' thrombolysed patients were collected. The median age was 71 (60-79), 56% were males, and the median baseline National Institute of Health Stroke Scale score was 13 ± 6.3. There was an 18-min reduction in the median door-to-needle time (90 min in 'pre-code stroke era' vs 72 min in 'code stroke era', P < 0.001). The rate of IV-tPA usage increased from 3.9% in 2004 to 17.3% in 2010. CONCLUSION: Our study showed that 'code stroke' rapid access protocol decreased door-to-needle time and possibly contributed to the increased IV-tPA usage.

The use of hyperbaric oxygen for preservation of free flaps.

The effects of hyperbaric oxygen (HBO) during tissue preservation on flap survival have been investigated in free flaps in rats. Groin skin flaps were harvested, stored in either room air or HBO (100% oxygen at 2.9 atm absolute) at 23 degrees C for 18 hours, and transplanted to the contralateral groin. Free flaps exhibit a high incidence of complete necrosis in the room air control. The survival of free flaps stored under HBO increased from 10% to 60% (p less than 0.05) after 18 hours of preservation. Skin flaps exhibited an increase in tissue hypoxanthine by 3.6-fold normal after 18 hours of storage in room air. HBO preservation prevented the accumulation of hypoxanthine and inhibited xanthine oxidase. Inhibition of the xanthine oxidase system may be one of the mechanisms of improved success of skin flap transplantation.