title: Screening with MRI for Accurate and Rapid Stroke Treatment: SMART.
abstract: OBJECTIVE
  The objective of this study was to demonstrate the feasibility of timely multimodal MRI screening before thrombolysis in acute stroke patients.
  
  
  METHODS
  Quality improvement processes were initiated in 2013 to reduce door-to-needle (DTN) time at the 2 hospitals where the NIH stroke team provides clinical care. Acute ischemic stroke (AIS) patients who received IV tissue plasminogen activator (tPA) ≤4.5 hours from last known normal were identified. Demographic and clinical characteristics and timing metrics were analyzed comparing the time periods before, during, and after the quality improvement processes.
  
  
  RESULTS
  There were 157 patients treated with IV tPA for AIS during 2012-2013, of whom 135 (86%) were screened with MRI. DTN time was significantly reduced by 40% during this period from a median of 93 minutes in the first half of 2012 to 55 minutes in the last half of 2013 (p < 0.0001) with a significant 4-fold increase in the proportion of treated patients with DTN time ≤60 minutes from 13.0% to 61.5%, respectively (p < 0.00001). Improvement in DTN time was associated with reduced door-to-MRI time, and there were no differences in demographic or clinical characteristics (p = 0.21-0.76).
  
  
  CONCLUSIONS
  It is feasible and practical to consistently and rapidly deliver IV tPA to AIS patients within national benchmark times using MRI as the routine screening modality. The processes used in the SMART (Screening with MRI for Accurate and Rapid Stroke Treatment) Study to reduce DTN time have the potential to be widely applicable to other hospitals.
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Shreyansh
authors.initials: S
authors.lastname: Shah
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Marie
authors.initials: M
authors.lastname: Luby
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Karen
authors.initials: K
authors.lastname: Poole
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Teresa
authors.initials: T
authors.lastname: Morella
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Keller
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Richard T
authors.initials: RT
authors.lastname: Benson
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: John K
authors.initials: JK
authors.lastname: Lynch
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD.
authors.forename: Zurab
authors.initials: Z
authors.lastname: Nadareishvili
authors.affiliation: From the Section on Stroke Diagnostics and Therapeutics (S.S., M.L., K.P., T.M., R.T.B., J.K.L., Z.N., A.W.H.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center Stroke Center (K.P., E.K., R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Program (T.M., Z.N.), Bethesda, MD. amie.hsia@medstar.net.
authors.forename: Amie W
authors.initials: AW
authors.lastname: Hsia
mesh_terms: D000208:Acute Disease; D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000473:pathology*; D002545:Brain Ischemia / Q000175:diagnosis / Q000473:pathology / Q000628:therapy*; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging / Q000379:methods; D058996:Quality Improvement; D020521:Stroke / Q000175:diagnosis / Q000473:pathology / Q000628:therapy*; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator