La influencia de la gestión organizativa en el tiempo puerta-aguja del tratamiento fibrinolítico / The influence of organisational management on door-to-needle times for fibrinolytic treatment

Introducción: El tiempo puerta-aguja (TPA) es el principal indicador del proceso del código ictus (CI). Según la guía de 2018 de la American Heart Association/American Stroke Associa-tion, el objetivo TPA debe ser inferior a 45 minutos. Para conseguirlo son necesarios protocolos eficaces y revisados de actuación extrahospitalaria e intrahospitalaria. Método: Analizamos la influencia de cambios organizativos entre 2011 y 2019 en el TPA y en la evolución clínica de los pacientes tratados con fibrinólisis. Utilizamos los datos de nuestro centro monitorizados y custodiados por el Pla Director en l’àmbit de la Malaltia Vascular Cerebral dela Generalitat de Catalunya. Entre otras medidas se han analizado las diferencias entre los a ̃nos y las derivadas de la implantación del modelo Helsinki. Resultados: Se estudiaron 447 pacientes, existiendo diferencias estadísticamente significativas en el TPA entre los diferentes a ̃nos. La activación del CI de forma extrahospitalaria en 315(70,5%) pacientes redujo el TPA una mediana de 14 minutos. Sin embargo, el modelo de regresión lineal sólo evidenció una relación inversamente proporcional entre la adopción del modelo deCI Helsinki (MH) y el TPA (coeficiente beta −0,42; p < 0,001). La eliminación de la figura delneurólogo vascular tras la adopción del MH empeoró el TPA y la mortalidad a los 90 días.Conclusión: El modelo organizativo influye en el TPA, siendo en nuestra muestra la aplicacióndel MH, la existencia de la figura del neurólogo vascular referente y la prenotificación del CIfactores claves para la reducción del TPA y la mejora clínica del paciente.(AU)

Introduction: Door-to-needle time (DNT) has been established as the main indicator in codestroke protocols. According to the 2018 guidelines of the American Heart Association/AmericanStroke Association, DNT should be less than 45 minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. Method: We analysed organisational changes made between 2011 and 2019 and their influenceon DNT and the clinical progression of patients treated with fibrinolysis. We collected datafrom our centre, stored and monitored under the Master Plan for Cerebrovascular Disease ofthe regional government of Catalonia. Among other measures, we analysed the differencesbetween years and differences derived from the implementation of the Helsinki model.Results: The study included 447 patients, and we observed significant differences in DNTbetween different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%),reduced DNT by a median of 14 minutes. However, the linear regression model only showed aninversely proportional relationship between the adoption of the Helsinki code stroke model andDNT (beta coefficient, —0.42; P < .001). The removal of vascular neurologists after the adoptionof the Helsinki model increased DNT and the 90-day mortality rate. Conclusion: DNT is influenced by the organisational model. In our sample, the application ofthe Helsinki model, the role of the lead vascular neurologist, and notification of code strokeby pre-hospital emergency services are key factors for the reduction of DNT and the clinicalimprovement of the patient.(AU)

The influence of organisational management on door-to-needle times for fibrinolytic treatment.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Eficacia de tenecteplase comparada con alteplase para tratamiento de ictus isquémico agudo. Una revisión narrativa

Introducción: La trombólisis intravenosa con Alteplase (ALT) se recomienda como tratamiento estándar siendo el único agente trombolítico aprobado por la FDA, en infarto cerebral. La Tenecteplase (TNK), un activador tisular del plasminógeno modificado, surge como agente antitrombótico alternativo. Esta revisión narrativa evalúa la evidencia actual y aborda los problemas prácticos sobre la eficacia y seguridad de tenecteplase en comparación con alteplase. Metodología: Se realizó una búsqueda sistemática y analítica de la literatura, y se proporcionó una síntesis cualitativa de metaanálisis y ensayos clínicos concluidos, que compararon la efectividad y seguridad de la tenecteplase con alteplase en el AIS, utilizando artículos indexados en MEDLINE, Cochrane Library y Scopus. Resultados: Los ensayos clínicos aleatorizados en su mayoría coinciden al encontrar que TNK es al menos tan o más efectiva que la ALT para mejoría neurológica después del AIS; mientras los metaanálisis coinciden en que los pacientes que recibieron TNK presentaron una mayor recanalización exitosa, pero difieren en cuanto a los hallazgos de mejoría neurológica temprana, resultado funcional a los 90 días y mortalidad a los 90 días. Conclusión: La tenecteplase es al menos tan eficaz como la Alteplase con respecto a la mejoría neurológica después del tratamiento del accidente cerebrovascular isquémico agudo.

Introduction: Intravenous thrombolysis with alteplase (ALT) is recommended as standard treatment, being the only thrombolytic agent approved by the FDA. Tenecteplase (TNK), a modified tissue plasminogen activator, is emerging as an alternative antithrombotic agent. This narrative review assesses the current evidence and addresses practical issues regarding the efficacy and safety of tenecteplase compared to alteplase. Methodology: A systematic and analytical search of the literature was performed, providing a qualitative synthesis of meta-analyses and completed clinical trials comparing the effectiveness and safety of tenecteplase with alteplase in AIS, using articles indexed in MEDLINE, the Cochrane Library, and Scopus. Results: Randomized clinical trials mostly agree in finding TNK to be at least as or more effective than ALT for neurological improvement after AIS; while the meta-analyses agree that patients who received TNK had more successful recanalization, they differ in terms of the findings of early neurological improvement, functional outcome at 90 days, and mortality at 90 days. Conclusion: Tenecteplase is at least as effective as alteplase with regard to neurological improvement after treatment of acute ischemic stroke.

Nuevos paradigmas: 12 años de trombólisis sistémica. Unidad ACV, Hospital de Clínicas / New paradigms: 12 years of systemic thrombolysis. Stroke Unit, Clinicas Hospital / Novos paradigmas: 12 anos de trombólise sistêmica. Unidade AVC, Hospital de Clínicas

Introducción: el ACV constituye un problema de salud y la trombólisis sistémica una estrategia de reperfusión con alto nivel de evidencia para su tratamiento. Los reportes nacionales sobre su utilización son escasos. Objetivos: comunicar y analizar los resultados de esta terapia en el Hospital de Clínicas. Establecer predictores de buena evolución, hemorragia intracraneana y mortalidad. Métodos: estudio observacional analítico de los pacientes trombolizados en el Hospital de Clínicas (2010-2021). Resultados: se realizó trombólisis sistémica a 268 pacientes. La mediana del NIHSS al ingreso fue 12 puntos. Un 42% fueron infartos totales de la circulación anterior. La cardioembolia constituyó la etiopatogenia más frecuente. El 59,3% de los pacientes fueron externalizados con independencia funcional y 55,2% con déficit neurológico mínimo. Las tasas de hemorragia intracraneana sintomática y mortalidad fueron 7,1% y 18,7% respectivamente. El 57% de los pacientes se trataron con tiempo puerta aguja ≤60 minutos. El porcentaje de trombólisis en el total de ACV fue 18,9%. La edad, NIHSS al ingreso e internación en unidad de ACV se comportaron como variables importantes para predecir buena evolución, hemorragia intracraneana y muerte. Discusión y conclusiones: se comunicó la mayor casuística nacional sobre el tema. Los parámetros de efectividad y seguridad del tratamiento fueron comparables a los reportados internacionalmente. Se destacaron los buenos tiempos puerta aguja y tasa trombólisis sobre ACV totales como indicadores satisfactorios de calidad asistencial. La internación en unidad de ACV se comportó como un factor predictor de independencia funcional y protector frente a mortalidad hospitalaria.

Introduction: Strokes are a health problem and systemic thrombolysis constitutes a reperfusion strategy backed up by significant evidence on its positive therapeutic impact. National reports on its use are scarce. Objectives: To report and analyze results obtained with this therapeutic approach at the Clinicas Hospital. To establish predictive factors for a good evolution, intracranial hemorrhage and mortality. Method: Observational, analytical study of thrombolysed patients at Clinicas Hospital (2010-2021). Results: Systemic thrombolysis was performed in 268 patients. Average NIHSS score was 12 points when admitted to hospital.42 % of cases were total anterior circulation infarct (TACI). Cardioembolic ischaemmic stroke was the most frequent etiopahogenesis. 59.3% of patients were discharged with functional independence and 55.2% had minimal neurologic deficit. Symptomatic intracranial hemorrhage and mortality rates were 7.1% and 18.7% respectively. 57% of patients were assisted within ≤60 minutes they showed up at the ER. Thrombolysis percentage in total number of strokes was 18.9%. Age, NIHSS score upon arrival to hospital and admission to the stroke unit were significant variables to predict a good evolution, intracranial hemorrhage and death. Discussion and conclusions: The large number of cases in the country was reported. Effectiveness and safety parameters for this treatment were comparable to those reported internationally. The good door-to-needle time and thrombolysis rate versus total number of strokes stood out as satisfactory indicators of healthcare quality. Admission to the stroke unit behaved as a predictive factor of functional independence and it protected patients from hospital mortality.

Introdução: o AVC é um problema de saúde sendo a trombólise sistêmica uma estratégia de reperfusão com alto nível de evidência para seu tratamento. Os dados nacionais sobre seu uso são escassos. Objetivos: comunicar e analisar os resultados desta terapia no Hospital de Clínicas. Estabelecer preditores de boa evolução, hemorragia intracraniana e mortalidade. Métodos: estudo observacional analítico de pacientes trombolisados no Hospital de Clínicas (2010-2021). Resultados: a trombólise sistêmica foi realizada em 268 pacientes. A mediana do índice NIHSS na admissão foi de 12 pontos. 42% eram infartos totais da circulação anterior. A cardioembolia foi a etiopatogenia mais frequente. 59,3% dos pacientes tiveram alta da unidade com independência funcional e 55,2% com déficit neurológico mínimo. As taxas de hemorragia intracraniana sintomática e mortalidade foram de 7,1% e 18,7%, respectivamente. 57% dos pacientes foram tratados com tempo porta-agulha ≤60 minutos. A porcentagem de trombólise no AVC total foi de 18,9%. Idade, NIHSS na admissão e internação na unidade de AVC se comportaram como variáveis importantes para prever boa evolução, hemorragia intracraniana e óbito. Discussão e conclusões: este trabajo inclui a maior casuística nacional sobre o tema. Os parâmetros de eficácia e segurança do tratamento foram comparáveis aos descritos na bibliografia internacional. Foram destacados como indicadores satisfatórios da qualidade do atendimento os bons tempos porta-agulha e taxa de trombólise em relação ao AVC total. A internação em unidade de AVC comportou-se como preditor de independência funcional e protetor contra a mortalidade hospitalar.

Tiempo puerta-aguja entre neurólogo presencial y localizado en ictus isquémico tratado con alteplasa. Estudio PRISA / Door-to-needle times for patients with ischaemic stroke treated with alteplase by on-site and off-site on-duty neurologists. PRISA study

Introducción: La guardia de neurología es frecuentemente presencial; es decir, con el neurólogo presente en el centro hospitalario; pero en algunos centros, puede ser localizada o mixta. La fibrinólisis intravenosa (FIV) es uno de los principales tratamientos reperfusores en el ictus isquémico agudo (IIA). El objetivo del siguiente trabajo es comparar el tiempo puerta-aguja (TPA) durante la guardia presencial y la guardia localizada. Material y métodos: Estudio prospectivo, observacional, desde el año 2012 hasta el año 2017 en el que se incluyeron pacientes con IIA y FIV. Se recogieron datos como sexo, edad, hora del inicio de los síntomas, hora de llegada al hospital, hora de la tomografía axial computarizada (TAC), hora de inicio de la FIV. Se consideró guardia de «Presencia» desde las 8:00 hasta las 20:00 y «Localizada» desde las 20:00 hasta las 08:00, divido en 3 grupos: guardia «Presencial», guardia «Localizada» y guardia «Localizada con residente». Resultados: N.° = 138; edad media 69,7 años; mujeres 45,7%. Pacientes en guardia de «Presencia» 96, «Localizada» 42, de los cuales 17 con residente. Ambos grupos presentaban características basales similares. Los TPA de los grupos «Presencia» y «Localizada» fueron 59 y 72 min, respectivamente (p = 0,003). Los TPA de grupos «Presencia», «Localizada» y «Localizada con residente», respectivamente 59, 74 y 68 min (p = 0,001), con significación entre «Presencia» y «Localizada». No se observaron diferentes entre el TPA dependiendo de la franja horaria de mañana, tarde y noche ni entre días laborales y días de fin de semana. Conclusión: La presencia o ausencia del neurólogo en el centro hospitalario en el momento del código ictus, influye en la demora de administración del tratamiento fibrinolítico. La presencia del residente de neurología puede acelerar la realización del proceso. (AU)

Background: Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. Methods: We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. Results: Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site–resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P = .003). DNTs were 59, 74, and 68 minutes (P = .001), respectively, for the on-site, off-site, and off-site–resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. Conclusion: DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT. (AU)

Door-to-needle times in patients treated by on-site and off-site on-call neurologists. PRISA study.

BACKGROUND: Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. METHODS: We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. RESULTS: Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72 minutes, respectively (P =  .003). DNTs were 59, 74, and 68 minutes (P =  .001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. CONCLUSION: DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.

Incidence, prognosis, and prediction of haemorrhagic transformation after revascularisation for stroke.

INTRODUCTION: Haemorrhagic transformation is a major complication of acute ischaemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial haemorrhage (ICH) after revascularisation therapy. METHODS: We conducted a retrospective, single-centre study including 235 patients with AIS who underwent intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy and/or endovascular treatment. A binary logistic regression model was used to determine the variables associated with ICH, parenchymal haematomas (PH), modified Rankin Scale (mRS) scores, and mortality. RESULTS: ICH was detected in 57 (30 with PH) of 183 patients included. Mechanical thrombectomy, either alone (OR 3.3 [1.42-7.63], P=.005) or in combination with IV-rtPA (OR 3.39 [1.52-7.56], P=.003), was associated with higher risk of ICH, while higher Alberta Stroke Program Early CT scores (OR 0.71 [0.55-0.91], P=.007) were associated with lower risk. Patients with older age (OR 1.07 [1.02-1.13], P=.006) and occlusion of the terminal branch of the internal carotid artery (OR 4.03 [1.35-11.99], P=.012) had a higher risk of PH, while the use of IV-rtPA alone (OR 0.24 [0.08-0.68], P=.008) was associated with lower risk of PH. Only PH was associated with disability as measured by the mRS (OR 3.2 [1.17-8.76], P=.02) and higher mortality (OR 5.06 [1.65-15.5], P=.005). CONCLUSIONS: Greater understanding about the predictors of ICH, mRS scores, and mortality could enable better selection of patients and treatments.

Incidencia, pronóstico y predicción de la transformación hemorrágica tras el tratamiento revascularizador del ictus / Incidence, prognosis, and prediction of haemorrhagic transformation after revascularisation for stroke

Introducción: La transformación hemorrágica es una complicación importante del ictus isquémico agudo (IIA). El propósito del trabajo es analizar el impacto clínico y los factores predictores de las hemorragias intracraneales (HIC) tras terapia revascularizadora.MétodosAnálisis retrospectivo monocéntrico de 235 pacientes con IIA tratados mediante trombólisis intravenosa (TIV) o tratamiento endovascular (TE). Se ha realizado un modelo de regresión logística binaria para determinar los factores asociados con las HIC, las hemorragias parenquimatosas (HP), la escala mRS y la mortalidad.ResultadosDe los 183 pacientes incluidos, 57 tuvieron HIC (30 HP). El TE mecánico (OR 3,3 [1,42-7,63], p = 0,005) y la TIV junto con TE mecánico (OR 3,39 [1,52-7,56], p = 0,003) se han asociado a mayor riesgo de HIC, mientras que valores altos de ASPECTS (OR 0,71 [0,55-0,91], p = 0,007) se han asociado a menor riesgo. Mayor edad (OR 1,07 [1,02-1,13], p = 0,006) y la oclusión de la carótida interna terminal (OR 4,03 [1,35-11,99], p = 0,012) han sido factores predictores de HP, mientras que haber recibido TIV exclusivamente (OR 0,24 [0,08-0,68], p = 0,008) se ha asociado con menor riesgo. Solo las HP se han asociado a valores invalidantes de mRS (OR = 3,2 [1,17-8,76], p = 0,02) y mayor mortalidad (OR 5,06 [1,65-15,5], p = 0,005).ConclusionesUna mejor comprensión de los factores predictores de HIC, mRS y mortalidad puede permitir una mejor selección de pacientes y tratamientos. (AU)

Introduction: Haemorrhagic transformation is a major complication of acute ischaemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial haemorrhage (ICH) after revascularisation therapy.MethodsWe conducted a retrospective, single-centre study including 235 patients with AIS who underwent intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy and/or endovascular treatment. A binary logistic regression model was used to determine the variables associated with ICH, parenchymal haematomas (PH), modified Rankin Scale (mRS) scores, and mortality.ResultsICH was detected in 57 (30 with PH) of 183 patients included. Mechanical thrombectomy, either alone (OR 3.3 [1.42-7.63], P=.005) or in combination with IV-rtPA (OR 3.39 [1,52-7.56], P=.003), was associated with higher risk of ICH, while higher Alberta Stroke Program Early CT scores (OR 0.71 [0.55-0.91], P=.007) were associated with lower risk. Patients with older age (OR 1.07 [1.02-1.13], P=.006) and occlusion of the terminal branch of the internal carotid artery (OR 4.03 [1.35-11.99], P = .012) had a higher risk of PH, while the use of IV-rtPA alone (OR 0.24 [0.08-0.68], P=.008) was associated with lower risk of PH. Only PH was associated with disability as measured by the mRS (OR 3.2 [1.17-8.76], P=.02) and higher mortality (OR 5.06 [1.65-15.5], P=.005).ConclusionsGreater understanding about the predictors of ICH, mRS scores, and mortality could enable better selection of patients and treatments. (AU)

A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment.

INTRODUCTION: Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays. MATERIAL AND METHODS: In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced. RESULTS: The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases. CONCLUSIONS: Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.

Un nuevo protocolo intrahospitalario reduce el tiempo puerta-aguja en el ictus agudo tratado con trombolisis intravenosa a menos de 30 minutos / A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment

Introducción: El objetivo del tiempo puerta-aguja en el ictus isquémico agudo tratado con trombólisis intravenosa (TIV) tiende a situarse actualmente en los 30 min. Determinamos si un nuevo protocolo de actuación intrahospitalario es eficaz para reducir el intervalo puerta-aguja y corregir los factores de demora previamente identificados.Material y métodosEn 2014 se implantaron gradualmente unas medidas diseñadas para acortar los tiempos de actuación intrahospitalarios en los pacientes tratados con TIV. Se compararon los tiempos de actuación antes (2009-2012) y después (febrero 2014-abril 2017) de la introducción del nuevo protocolo.ResultadosSe incluyeron 239 pacientes antes y 222 después. Cuando todas las medidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 27 min (previa 52 min, 48% menos, p < 0,001) y de 22 min cuando se activó el código ictus extrahospitalario. El tiempo global al tratamiento (inicio-aguja) se redujo en 26 min de mediana (p < 0,001). En el período postintervención ya no se objetivó el «efecto de fin de ventana» (p = 0,98). Aunque la angio-TC antes de la TIV continuó retrasando los tiempos de actuación (p < 0,001), tras el nuevo protocolo, esta prueba se realizó después del inicio del tratamiento en la mayoría de los casos.ConclusionesLa reorganización intrahospitalaria y la colaboración multidisciplinar han situado la mediana de tiempo puerta-aguja por debajo de los 30 min y han corregido los factores de demora identificados previamente. Además, se ha reducido el tiempo global al tratamiento y una mayor proporción de pacientes son tratados en los primeros 90 min desde el inicio de los síntomas. (AU)

Introduction: Recent analyses emphasize that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30 min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays.Material and methodsIn 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced.ResultsThe sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27 min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52 minutes], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22 min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the «3-hour-effect» did not affect door-to-needle time time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases.ConclusionsHospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30 min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90 min of symptom onset. (AU)

Retraso en la administración de tratamiento trombolítico en el ictus minor / Delayed administration of thrombolytic therapy in minor stroke

Introducción: Se considera ictus minor a aquel que se presenta con escasos síntomas; sin embargo, hasta un 40% presenta discapacidad a largo plazo. La tasa de trombólisis en estos pacientes también es inferior a la del resto de ictus. En este estudio se pretende explorar si existen diferencias en los tiempos de atención en la trombólisis intravenosa en los pacientes con ictus minor. Material y métodos. Revisión retrospectiva de los ictus tratados con trombólisis intravenosa en nuestro centro y análisis comparativo de los tiempos de asistencia entre ictus minor y el resto. Resultados: Se encontraron tiempos más alargados en los casos de ictus minor en cuanto al tiempo puerta-tomografía computarizada y puerta-aguja. No fue así, sin embargo, para el tiempo desde el inicio de los síntomas hasta la llegada al hospital. Conclusiones: La presencia de escasos síntomas en el ictus minor puede hacer difícil su reconocimiento y podría ser un motivo de retraso en el tratamiento. La formación entre el personal que atiende a estos pacientes es fundamental para mejorar este aspecto.(AU)

Introduction: Minor strokes are considered to be those that present with few symptoms, although up to 40% of them entail long-term disability. The rate of thrombolysis in these patients is also lower than in other strokes. The aim of this study is to explore whether there are any differences in intravenous thrombolysis care times in minor strokes. Patients and methods: We conducted a retrospective review of strokes treated with intravenous thrombolysis at our centre and a comparative analysis of the care times in minor strokes and in the other types. Results: Longer times were found in minor strokes in terms of door-to-CT scan and door-to-needle time. This was not the case, however, for the time from the onset of symptoms to arrival at the hospital. Conclusions: The presence of few symptoms in minor strokes can make them difficult to recognise and could be a reason for delaying treatment. Training among staff caring for these patients is essential to improve this aspect.(AU)

The influence of organisational management on door-to-needle times for fibrinolytic treatment. / La influencia de la gestión organizativa en el tiempo puerta-aguja del tratamiento fibrinolítico.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Door-to-needle times for patients with ischaemic stroke treated with alteplase by on-site and off-site on-duty neurologists. PRISA study. / Tiempo puerta-aguja entre neurólogo presencial y localizado en ictus isquémico tratado con alteplasa. Estudio PRISA.

BACKGROUND: Hospital on-call neurology shifts are frequently on-site, but some on-call services may be off-site or mixed. Intravenous tissue plasminogen activator (tPA) is one of the main reperfusion treatments for acute ischaemic stroke (AIS). This study assesses door-to-needle times (DNT) when the neurologist is on-site or off-site. METHODS: We performed a prospective, observational study from 2012 to 2017, including patients with AIS and treated with tPA. Data were collected on sex, age, door-to-scan time, scan-to-needle time, and DNT. The on-duty neurologist was on-site from 08:00 to 20:00, and on call but off-site from 20:00 to 8:00. Three groups were formed: on-site, off-site, and off-site with resident present. RESULTS: Our sample included 138 patients. The mean age was 69.7 years, and 45.7% of patients were women. Ninety-six patients were admitted during the on-site shift, 25 during the off-site shift, and 17 during the off-site-resident present shift. Patients admitted during the on-site and off-site shifts presented DNTs of 59 and 72minutes, respectively (P=.003). DNTs were 59, 74, and 68minutes (P=.001), respectively, for the on-site, off-site, and off-site-resident present shifts; the difference between DNTs for on-site and off-site shifts was statistically significant. No differences were observed between DNTs according to time of day (morning, afternoon, or night), or between weekdays and weekends. CONCLUSION: DNT is influenced by whether the on-duty neurologist is on- or off-site at the time of code stroke activation. The presence of a neurology resident can reduce DNT.

Incidence, prognosis, and prediction of haemorrhagic transformation after revascularisation for stroke. / Incidencia, pronóstico y predicción de la transformación hemorrágica tras el tratamiento revascularizador del ictus.

INTRODUCTION: Haemorrhagic transformation is a major complication of acute ischaemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial haemorrhage (ICH) after revascularisation therapy. METHODS: We conducted a retrospective, single-centre study including 235 patients with AIS who underwent intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy and/or endovascular treatment. A binary logistic regression model was used to determine the variables associated with ICH, parenchymal haematomas (PH), modified Rankin Scale (mRS) scores, and mortality. RESULTS: ICH was detected in 57 (30 with PH) of 183 patients included. Mechanical thrombectomy, either alone (OR 3.3 [1.42-7.63], P=.005) or in combination with IV-rtPA (OR 3.39 [1,52-7.56], P=.003), was associated with higher risk of ICH, while higher Alberta Stroke Program Early CT scores (OR 0.71 [0.55-0.91], P=.007) were associated with lower risk. Patients with older age (OR 1.07 [1.02-1.13], P=.006) and occlusion of the terminal branch of the internal carotid artery (OR 4.03 [1.35-11.99], P = .012) had a higher risk of PH, while the use of IV-rtPA alone (OR 0.24 [0.08-0.68], P=.008) was associated with lower risk of PH. Only PH was associated with disability as measured by the mRS (OR 3.2 [1.17-8.76], P=.02) and higher mortality (OR 5.06 [1.65-15.5], P=.005). CONCLUSIONS: Greater understanding about the predictors of ICH, mRS scores, and mortality could enable better selection of patients and treatments.

Factors associated with in-hospital delays in treating acute stroke with intravenous thrombolysis in a tertiary centre. / Identificación de los factores que influyen en el retraso intrahospitalario del inicio de trombólisis intravenosa en el ictus agudo en un hospital terciario.

OBJECTIVE: This study aims to determine which factors are associated with delays in door-to needle (DTN) time in our hospital. This will help us design future strategies to shorten time to treatment with intravenous thrombolysis (IVT). METHODS: Retrospective analysis of a prospective cohort of patients with ischaemic stroke treated with IVT in our hospital between 2009 and 2012. We analysed the relationship between DTN time and the following variables: age, sex, personal medical history, onset-to-door time, pre-hospital stroke code activation, blood pressure and blood glucose level, National Institutes of Health Stroke Scale (NIHSS), computed tomography angiography (CTA) and/or doppler/duplex ultrasound (DUS) performed before IVT, time to hospital arrival, and day of the week and year of stroke. RESULTS: Our hospital treated 239 patients. Median time to treatment in minutes (IQR): onset-to-door, 84 (60-120); door-to-CT, 17 (13-24.75); CT-to needle, 34 (26-47); door-to-needle, 52 (43-70); onset-to-needle, 145 (120-180). Door-to-needle time was significantly shorter when code stroke was activated, at 51 vs. 72min (P=0.008), and longer when CTA was performed, at 59 vs. 48.5min (P=0.004); it was also longer with an onset-to-door time<90min, at 58 vs. 48min (P=0.003). The multivariate linear regression analysis detected 2 factors affecting DTN: code stroke activation (26.3% reduction; P<0.001) and onset-to-door time (every 30min of onset-to-door delay corresponded to a 4.7min increase in DTN time [P=0.02]). On the other hand, CTA resulted in a 13.4% increase in DTN (P=0.03). No other factors had a significant influence on door-to-needle time. CONCLUSIONS: This study enabled us to identify CTA and the «3-hour effect¼ as the 2 factors that delay IVT in our hospital. In contrast, activating code stroke clearly reduces DTN. This information will be useful in our future attempts to reduce door-to-needle times.