title: Stroke prenotification is associated with shorter treatment times for warfarin-associated intracerebral hemorrhage.
abstract: BACKGROUND
  Warfarin-associated intracerebral hemorrhage (WAICH) is a devastating disease with increasing incidence. In this setting, treatment with prothrombin complex concentrates (PCC) is essential to correct coagulopathy. Yet despite the availability of coagulopathy correction strategies, significant treatment delays can occur in emergency departments (EDs), which may be overcome using stroke prenotification strategies. To explore this, we compared arrival-to-treatment times with PCC for WAICH between two different stroke response systems that used the same international normalized ratio (INR) correction protocol.
  
  
  METHODS
  We established a registry of consecutive patients presenting with WAICH and treated with PCC presenting to two Canadian tertiary-care academic stroke centers: one with a stroke prenotification system, and one with a traditional ED assessment, treatment and referral system. In this comparative cohort design, we defined the WAICH diagnosis time as the earliest time point where both INR and CT were available. We compared median times from arrival to treatment, as well as arrival to diagnosis, and diagnosis to treatment.
  
  
  RESULTS
  Between 2008 and 2010, we collected data from 123 consecutive patients with intracranial hemorrhage who received PCC for INR correction (79 from ED referral, and 44 prenotification). Onset-to-arrival times, demographics, Glasgow Coma Scale scores, and baseline INR were similar between the two systems. Arrival-to-treatment times were significantly shorter in the prenotification system as compared to the traditional ED referral system (135 vs. 267 min; p = 0.001), which was driven by both decreased arrival-to-diagnosis time (49 vs. 117 min; p = 0.006), as well as decreased diagnosis-to-treatment time (56 vs. 112 min; p < 0.001). Arrival-to-scan times and arrival-to-INR times were similarly shorter in the prenotification system (68 vs. 118 min and 20.5 vs. 47 min, respectively).
  
  
  CONCLUSIONS
  Stroke prenotification was associated with shorter arrival-to-treatment times for emergent INR correction in patients with WAICH, which was driven by both faster diagnosis and treatment. Our results are consistent with those seen in ischemic stroke, suggesting that prenotification systems present an opportunity to optimize acute intracerebral hemorrhage therapy.
authors.affiliation: Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont., Canada.
authors.forename: Dar
authors.initials: D
authors.lastname: Dowlatshahi
authors.forename: Jason K
authors.initials: JK
authors.lastname: Wasserman
authors.forename: Ken S
authors.initials: KS
authors.lastname: Butcher
authors.forename: Manya L
authors.initials: ML
authors.lastname: Bernbaum
authors.forename: A Adam
authors.initials: AA
authors.lastname: Cwinn
authors.forename: Antonio
authors.initials: A
authors.lastname: Giulivi
authors.forename: Eddy
authors.initials: E
authors.lastname: Lang
authors.forename: Man-Chiu
authors.initials: MC
authors.lastname: Poon
authors.forename: Jessica
authors.initials: J
authors.lastname: Tomchishen-Pope
authors.forename: Mukul
authors.initials: M
authors.lastname: Sharma
authors.forename: Shelagh B
authors.initials: SB
authors.lastname: Coutts
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D002545:Brain Ischemia / Q000175:diagnosis* / Q000209:etiology*; D002170:Canada; D002543:Cerebral Hemorrhage / Q000139:chemically induced / Q000150:complications* / Q000628:therapy; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000175:diagnosis* / Q000209:etiology*; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin