Accuracy of First Recorded “Last Known Normal” Times of Stroke Code Patients

Abstract

Introduction Given the time-sensitivity of thrombolytic therapy, the accurate documentation of last known normal (LKN) time is crucial to ensure optimal management of stroke patients. This study investigates whether a difference exists between preliminary LKN times (first responders and ED practitioners) and revised LKN times (neurology/stroke practitioners), and what potential impact on emergent management of acute stroke this discrepancy may pose. Methods All stroke code patients from UCSD hospitals from 10/2008 to 7/2013 with treatment time data were included and grouped based on the disparity between preliminary LKN time and revised LKN time: preliminary earlier than revised, two times equal, and preliminary later than revised. We compared baseline characteristics, stroke code intervals, rates of rt-PA administration, 90 day mRS score, discharge disposition, and symptomatic intracranial hemorrhage. Results 73.6% of 261 patients had disparity between preliminary and revised times. 57.5% had later preliminary LKN than revised; 16.1% had earlier preliminary LKN than revised. Baseline characteristics, stroke code speed, 90 day mRS score, rates of rt-PA administration, discharge disposition, or rates of sICH were not significantly different between the groups. Among rt-PA treated stroke patients whose preliminary time was earlier than the revised time, had the preliminary LKN been used, 29.4% would have had rt-PA withheld inappropriately. In those stroke patients excluded from rt-PA treatment for being outside the treatment window, whose preliminary time was later than the revised time, had the preliminary time been used, 69.7% would have been inappropriately treated outside the relevant rt-PA window. Conclusions Most patients had disparity between preliminary and revised LKN times. Had the preliminary LKN time been used for acute stroke decision making, 58% of patients would have potentially been treated outside the approved thrombolytic time window, with higher risk of adverse events and 16% may have been inappropriately excluded from thrombolysis. This study highlights the need for training in the determination and refinement of the actual time of stroke onset, especially at hospitals without stroke expertise.

Futile complete recanalization: patients characteristics and its time course

“…A recent study reported that the effect of complete reperfusion was retained among patients who underwent mechanical thrombectomy after 6 hours of stroke onset 26 . Onset-to-puncture time may be less critical than puncture-to-reperfusion time with respect to the effect of complete reperfusion, because onset-to-puncture time is sometimes imprecisely determined or documented 27 , while puncture-to-reperfusion time is generally accurately documented.…”

Tissue plasminogen activator; identifying major barriers related to intravenous injection in ischemic acute cerebral infraction

“…In 2012, the stroke academic industry roundtable suggested beneficial assessment of (1) neuroprotective agents, (2) IV-tPA, and (3) emerging treatments to decrease reperfusion damage. [12345678910111213141516171819202122232425262728293031] Henninger and Fisher reported that <10% of all patients with AIS receive intravenous thrombolysis and it has been expected that only around 7%–15% of AIS patients are qualified for acute endovascular intervention. [29]…”

“…A previous publication by Spokoyny et al ., in 2015, highlighted the necessity for informative package associated to the determination and modification of the certain time of stroke onset, particularly at hospital without stroke expertise. [10]…”

“…Hyper- and hypo-fibrinolysis could be caused by increased or decreased activity which can result in excessive bleeding, thrombosis, or embolism. [678910] Even though the prescription of tPA for AIS has been increased in the current years, the total degree of its use remains to be low. [11]…”

Pharmacotherapy Updates of Recombinant Tissue Plasminogen Activator (r-TPA) in Acute Ischemic Stroke

“…According to a recently published article by Spokoyny et al (19), to confirm ideal supervision of patients with AIS, the precise documentation of last known normal time seems to be critical. Due to the time sensitivity of thrombolytic therapy, there is need for training in the determination and alteration of the actual time of stroke onset.…”