title: Streamlining door to recanalization processes in endovascular stroke therapy.
abstract: BACKGROUND
  In acute stroke due to large vessel occlusion, faster reperfusion leads to better outcomes. We analyzed the effect of optimization steps aimed to reduce treatment delays at our center.
  
  
  METHODS
  Consecutive patients with ischemic stroke treated with endovascular therapy were prospectively analyzed. We divided the patients into pre-optimization (20 April 2012 to 8 October 2013) and post-optimization (9 October 2013 to 29 July 2014) periods. The main interventions included: (1) continuous feedback; (2) standardized immediate emergency department attending to stroke attending communication with interventional team activation for all potential interventions; (3) pre-notification by the emergency medical service; (4) minimizing additional diagnostic testing; (5) direct transport to the CT scanner; (6) transport directly from the CT scanner to the angiography suite. The main metric used to measure improvement was door to groin puncture time (D2P).
  
  
  RESULTS
  We included a total of 286 patients (178 pre-optimization, 108 post-optimization). There were no significant differences between major baseline characteristics between the groups with the exception of higher median CT Alberta Stroke Program Early CT Score in the pre-optimization group (p=0.01). Median D2P improved from 105 min pre-optimization to 67 min post-optimization (p=0.0002). Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, with a trend toward a better outcome in the post-optimization group in a subgroup analysis of patients with anterior circulation occlusion who received intravenous tissue plasminogen activator.
  
  
  CONCLUSIONS
  This pilot study demonstrates that D2P times can be significantly reduced with a standardized multidisciplinary approach. There was no significant difference in the rate of 3-month good outcome, which is most likely due to the small sample size and confounding baseline patient characteristics.
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Amin
authors.initials: A
authors.lastname: Aghaebrahim
authors.affiliation: Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Streib
authors.affiliation: Department of Neurology, Emory University, Atlanta, Georgia, USA.
authors.forename: Srikant
authors.initials: S
authors.lastname: Rangaraju
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Kenmuir
authors.affiliation: Winchester Neurological Consultants, Winchester, Virginia, USA.
authors.forename: Dan-Victor
authors.identifier: http://orcid.org/0000-0002-8065-6821
authors.initials: DV
authors.lastname: Giurgiutiu
authors.affiliation: Soroka Medical Center, Beersheba, Israel.
authors.forename: Anat
authors.initials: A
authors.lastname: Horev
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Yumna
authors.initials: Y
authors.lastname: Saeed
authors.affiliation: Department of Emergency Medicine, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Clifton W
authors.initials: CW
authors.lastname: Callaway
authors.affiliation: Department of Emergency Medicine, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Francis X
authors.initials: FX
authors.lastname: Guyette
authors.affiliation: Department of Emergency Medicine, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Martin-Gill
authors.affiliation: Department of Emergency Medicine, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.
authors.forename: Charissa
authors.initials: C
authors.lastname: Pacella
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.|Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Ducruet
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.|Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Jankowitz
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.|Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Tudor G
authors.initials: TG
authors.lastname: Jovin
authors.affiliation: Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA.|Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Ashutosh P
authors.initials: AP
authors.lastname: Jadhav
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000628:therapy; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D015424:Reperfusion / Q000379:methods* / Q000592:standards; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy*; D017131:Thrombectomy / Q000009:adverse effects; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D061665:Time-to-Treatment / Q000592:standards; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Intervention; Stroke; Thrombectomy