Clot Busters Delivered in an Hour, Even With MRI

This is still a f*cking appalling amount of time. I'm sure that is still not fast enough to stop the neuronal cascade of death.
http://www.medpagetoday.com/Neurology/Strokes/51662?
It's possible to get door-to-needle (DTN) time for tPA administration in acute ischemic stroke down to 60 minutes or less when using MRI in place of CT for decision-making, researchers found.
Two centers -- one academic, one community -- that use MRI as part of an NIH study dropped their median DTN time from 93 to 55 minutes after focusing their workflow processes, Amie Hsia, MD, of MedStar Washington Hospital Stroke Center, and colleagues reported online in Neurology.

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"Our fastest times were 36 to 37 minutes, we didn't even think that was achievable with MRI," Hsia told MedPage Today. "It shows the power of a focused effort to make a process more efficient."
The academic center MedStar Washington Hospital Center and the community Suburban Hospital participated in a National Institute for Neurological Disorders and Stroke study to evaluate the utility of MRI in stroke diagnosis and treatment.
Hsia said that given a large international push to decrease DTN times to within 60 minutes of arrival at a hospital, her team "had to respond to this" even though the use of MRI takes longer than CT to perform.
Yet MRI has been said to hold advantages over CT in stroke diagnosis and treatment, since it can give better information about the size and location of the ischemia, its duration, the presence of hemorrhage and vessel occlusion, and greater insight into underlying etiology.
To assess whether MRI use was compatible with DTN times of 60 minutes or less, Hsia and colleagues conducted the Screening with MRI for Accurate and Rapid stroke Treatment (SMART) study. They performed a "lean process" analysis of their protocol, inspired by Andria Ford, MD, of Washington University in St. Louis, who had done the same for CT in stroke and who wrote an editorial accompanying the Neurology paper.

The researchers made several improvements, but noted a few that were key.

• The team more closely defined roles for all staff involved, from the ED and stroke nurses and techs to the physicians, to increase "ownership."
• They simplified an extensive MRI clearance form to one more suitable for emergency situations.
• The MRI tech was paged when stroke patients were incoming.
• Physicians gave tPA in the MRI room, instead of waiting for patients to return to the ED.

Hsia also distributed T-shirts to staff when the process was completed within 60 minutes or less to thank each team member for the part they played. Those improved processes were implemented halfway into the MRI study, allowing comparison of response times before and after.
A total of 1,066 patients were studied at both centers, and 86% were screened with MRI before treatment. About 15%, or 157 patients, were treated with tPA.
Hsia and colleagues found a significant 40% reduction in median DTN time, from 93 to 55 minutes (P<0.0001), and fourfold increase in the proportion of patients treated with IV tPA in less than 60 minutes during the study period -- from 13% in the first half of 2012 to 61.5% in first half of 2013.
Rates of in-hospital mortality, discharge to home or inpatient rehabilitation, and modified Rankin Scale score weren't significantly different across the study period, and stroke mimic rate remained consistently 0%, suggesting that with an "an improvement in efficiency, there was no detrimental effect on safety," Hsia said.

"Patients weren't having worse outcomes by us quickening the process," Hsia said. "It's important that we didn't increase the stroke mimic rate. Reducing times didn't impact our accuracy."
Editorialists Ford and Ronen Leker, MD, of the Peritz and Chantal Sheinberg Cerebrovascular Laboratory in Jerusalem, said the study suggests a future role for MRI in diagnosing and treating stroke, as the sensitivity and specificity of MRI for acute ischemic stroke exceed those of CT.
But they noted that even if acquisition times for MRI can rival those of CT, MRI would still likely be used less because of its limited availability, greater cost, and more common contraindications.
"Despite the clear need for further work, MRI for tPA decision-making may not be too far down the road," they wrote. "The current study reminds us of the dramatic effects on DTN times generated from focused, team-based quality improvement measures incorporating lean manufacturing principles -- implementation can yield these beneficial effects within a short amount of time."
"While CT remains the standard of care for acute tPA decision-making," they added, "continued work toward utilizing and interpreting MRI in a streamlined manner may eventually provide patients with the best care, balancing both time and accuracy."

My comment on this;
I would expect that once we can accurately identify the type of stroke via the xPrize tricorder, or eye-tracking, or Ischiban headband, or the drop of blood testing, we should be able to deliver this in the ambulance. That might be fast enough to not trigger the neuronal cascade of death.  55 minutes is still way too slow, the goal has to be ambulance delivered and not the CT scanner ambulances.