Patients with Low National Institutes of Health Stroke Scale Scores Have Longer Door-to-Needle Times: Analysis of a Telestroke Network.
BACKGROUND
The benefits of intravenous tissue-type plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) are time dependent. Because emergency rooms quickly initiate a stroke alert with more severe symptoms, we hypothesized that patients with lower National Institutes of Health Stroke Scale (NIHSS) scores, indicating a less severe stroke, would have longer door-to-needle (DTN) times compared to patients with higher NIHSS scores.


METHODS
Data obtained from the 19-hospital Providence Stroke Registry were used to identify AIS patients who received IV-tPA within 4.5 hours of last-known-well. NIHSS scores were obtained prior to tPA administration at the time of emergency department presentation and categorized as low-NIHSS (score = 0-5) or high-NIHSS (score = 6-42) strokes. Median DTN times were collected for both groups as the primary outcome variable. Linear mixed-effects regression models were used to assess the effect of NIHSS scores on DTN and its 2 components: door-to-CT (DCT) and CT-to-needle (CTN) times.


RESULTS
We identified 692 AIS patients who received IV-tPA within 4.5 hours of last-known-well, with 198 patients presenting with low-NIHSS strokes and 494 patients with high-NIHSS strokes. In multivariable analysis, median DTN time was estimated to be 18% higher for low-NIHSS strokes than high-NIHSS strokes after adjusting for covariates (P < .001). Median DCT times were also higher for low-NIHSS (19 minutes) compared to high-NIHSS (11 minutes) strokes after adjusting for covariates (P < .001), whereas CTN times were unchanged (P = .055).


CONCLUSIONS
In AIS patients receiving IV-tPA in a telestroke network, lower NIHSS scores were associated with longer DTN and DCT times.
Providence Brain and Spine Institute, Portland, Oregon. Electronic address: archit.bhatt@providence.org.
Archit
A
Bhatt
Providence Brain and Spine Institute, Portland, Oregon.
Alexandra
A
Lesko
Providence Brain and Spine Institute, Portland, Oregon.
Lindsay
L
Lucas
Providence Brain and Spine Institute, Portland, Oregon.
Amit
A
Kansara
Providence Brain and Spine Institute, Portland, Oregon.
Elizabeth
E
Baraban
D003195:Computer Communication Networks / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D016014:Linear Models; D008297:Male; D009316:National Institutes of Health (U.S.) / Q000592:standards*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy*; D061665:Time-to-Treatment / Q000592:standards*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
NIHSS; Stroke; alteplase; thrombolysis