title: Endovascular Stroke Therapy Results Improve over Time: The 'Learning Curve' at a New Comprehensive Stoke Center.
abstract: BACKGROUND
  The requirements for a comprehensive stroke center (CSC) include the capability to perform endovascular stroke therapy (EST). EST is a complex process requiring early identification of appropriate patients and effective delivery of intervention. In order to provide prompt intervention for stroke, CSCs have been established away from large academic centers in community-based hospitals. We hypothesized that quantifiable improvements would occur during the first 2 years of a community-based CSC as the processes and personnel evolved. We report the results over time of EST at a new community-based CSC.
  
  
  METHODS
  We have retrospectively analyzed demographic data and outcome metrics of EST from the initiation phase of a new community-based CSC. Data was divided into year 1 and year 2. Statistical analysis (Student's t test and Fisher's exact test) was performed to compare the patient population and outcomes across the two time periods. Outcome variables included the thrombolysis in cerebral infarction (TICI) score, a change in the NIH stroke scale score and the modified Rankin Scale (mRS) score. Analysis of variance (ANOVA) was used to statistically analyze the relationship between population variables and outcome. Computed tomography (CT) angiography and CT perfusion analysis were used to select patients for EST. Approximately half of the patients undergoing EST were excluded from receiving intravenous recombinant tissue plasminogen activator (IV rt-PA) by standard criteria, while the other half showed no sign of improvement following 1 h of IV rt-PA treatment. Mechanical thrombolysis with a stentriever was performed in the majority of cases with or without intra-arterial medication. The majority of treated occlusions were in the middle cerebral artery.
  
  
  RESULTS
  A total of 18 patients underwent EST during year 1 and year 2. A statistically significant increase in good outcomes (mRS score ≤2 at discharge) was seen from year 1 to year 2 (p = 0.05). There were trends towards faster interventions, decreased complications and mortality as well as an improved TICI score from year 1 to year 2. With ANOVA, mortality was statistically correlated with age (p = 0.06), while decreases in the NIH stroke scale (NIHSS) score following EST correlated with decreased mortality (p = 0.01). A higher TICI score was significantly associated with a decreased NIHSS score following EST (p = 0.01).
  
  
  CONCLUSIONS
  At a new community-based CSC, improved outcome occurred from year 1 to year 2, and trends towards decreased mortality, fewer complications, and improved revascularization were observed. Furthermore, the data shows that improvement in NIHSS score after EST is associated with decreased mortality following stroke in this setting, implying a net benefit.
authors.affiliation: Clinical Neuroscience Program, Kennedy Memorial Hospital, Washington Township, N.J., and Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pa., USA.
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Benardete
authors.affiliation: Clinical Neuroscience Program, Kennedy Memorial Hospital, Washington Township, N.J., and Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pa., USA.
authors.forename: Anil K
authors.initials: AK
authors.lastname: Nair
keywords: Endovascular stroke therapy; Quality improvement; Stroke; Stroke care organization; Stroke care quality; Stroke center