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.
