Catheter-Based Stroke Treatment Standards Set

If we can't even simply get tPA in within 3 hours I don't see this ocurring.
http://www.medpagetoday.com/Cardiology/Strokes/37217?
When IV thrombolysis won't work, intra-arterial treatment for stroke should start within 2 hours of hospital arrival and result in a good outcome in at least 30% of patients, according to benchmarks agreed on by eight professional societies.
The document set out minimum standards for individual practitioner performance in catheter-based stroke revascularization and called for their use in quality assurance programs and in a national outcomes registry.
The 2-hour time from door to arterial puncture recommended regardless of clinical evaluation and imaging details was acknowledged as ambitious in the February issue of the Journal of Vascular and Interventional Radiology.
"This is more rapid than reported in previous trials, but it is the consensus of the writing group that this time metrics are necessary and achievable, and consistent with the improvement in door-to-balloon times that have been achieved for acute myocardial infarction," David Sacks, MD, of Reading Hospital and Medical Center in West Reading, Penn., and colleagues wrote.
Prior studies suggested an average 174 minutes to catheter placement with CT imaging and 162 minutes to groin puncture with MRI.
Adding in anesthesia services, emergency medicine, and interventional components adds up to at least an extra hour, or even 2 hours in some centers, to start endovascular stroke treatment compared with acute myocardial infarction (MI).
"Notwithstanding that, it is clear that, similar to the cardiology model, major improvements in door-to-treatment times need to take place to increase the proportion of favorable outcomes for patients treated with endovascular therapy for acute stroke," Sacks's group wrote.
They set the minimum at 75% of patients receiving treatment with a door to puncture time of less than 2 hours.
The threshold for performance on patient outcomes was at least 30% of stroke patients treated endovascular with a good neurologic functional outcome at 90 days, defined by a score of 0 to 2 on the modified Rankin Scale.
This metric lumped together anterior and posterior strokes, pharmacologic and mechanical revascularization, and all stroke severities, demographics, and clot locations.
Treating sicker patients may mean physicians don't meet the benchmarks, the document noted.
"This does not mean such physicians are providing a lower quality of care, but rather that such physicians have chosen to treat a different patient mix from those patients entered into the trials used to generate these benchmarks," according to the guidelines, which recommended that such a practice should be justified in documentation.
Quality assurance guidelines are necessary, Sacks's group explained, because it remains to be proven in randomized trials that mechanical revascularization holds advantage over pharmacologic lysis, yet these procedures have entered standard clinical practice in many places.
Other metrics set out in their document included:

• All patients should have their process and outcomes data entered into a national database, trial, or registry
• At least 80% of patients evaluated for acute stroke revascularization should have a noncontrast head CT or MRI study within 25 minutes of hospital arrival and have it interpreted within 45 minutes of arrival
• Half or more of patients should have a time from puncture to start of lytic infusion or first pass of mechanical device in the target vessel of less than 45 minutes
• At least 50% of patients should have TIMI grade 2 or TICI grade 2a revascularization within 90 minutes of arterial puncture
• At least 60% of patients should have TIMI grade 2 or TICI grade 2/3 recanalization across all clot locations when the procedure is done
• At least 90% of patients should have a brain CT or MR imaging study within 36 hours after the procedure
• All deaths within 72 hours of the end of the procedure and all symptomatic intracerebral hemorrhages should be reviewed
• No more than 12% of treated patients should develop symptomatic intracerebral hemorrhage

"Symptomatic intracerebral hemorrhages is not only an 'end-result' evaluation of clinical judgment in the realm of patient selection and technical skill, but also a reflection of timing, procedural execution, and expeditious completion of task," the document stated in explaining why tracking it was mandatory.
The guidelines came from consensus among the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology.