One-Stop Management with Perfusion for Transfer Patients with Stroke due to a Large-Vessel Occlusion: Feasibility and Effects on In-Hospital Times

Abstract

BACKGROUND AND PURPOSE:In-hospital time delays lead to a relevant deterioration of neurologic outcomes in patients with stroke with large-vessel occlusions. At the moment, CT perfusion is relevant in the triage of late-window patients with stroke. We conducted this study to determine whether one-stop management with perfusion is feasible and leads to a reduction of in-hospital times. MATERIALS AND METHODS:In this observational study, we report the first 15 consecutive transfer patients with stroke with externally confirmed large-vessel occlusions who underwent flat panel detector CT perfusion and thrombectomy in the same room. Preinterventional imaging consisted of noncontrast flat panel detector CT and flat panel detector CT perfusion, acquired with a biplane angiography system. The flat panel detector CT perfusion was used to reconstruct a flat panel detector CT angiography to confirm the large-vessel occlusions. After confirmation of the large-vessel occlusion, the patient underwent mechanical thrombectomy. We recorded time metrics and safety parameters prospectively and compared them with those of transfer patients whom we treated before the introduction of one-stop management with perfusion. RESULTS:Fifteen transfer patients underwent flat panel detector CT perfusion and were treated with mechanical thrombectomy from June 2017 to January 2019. The median time from symptom onset to admission was 241 minutes. Median door-to-groin time was 24 minutes. Compared with 23 transfer patients imaged with multidetector CT, it was reduced significantly (24 minutes; 95% CI, 19 -37 minutes, versus 53 minutes; 95% CI, 44 -66 minutes; P Ͻ .001). Safety parameters were comparable between groups. CONCLUSIONS:In this small series, one-stop management with perfusion led to a significant reduction of in-hospital times compared with our previous workflow. ABBREVIATIONS:FPDCT ϭ flat panel detector CT; ICH ϭ intracranial hemorrhage; IQR ϭ interquartile range; LVO ϭ large-vessel occlusion; MDCT ϭ multidetector CT

Management of acute ischemic stroke

“…Time to reperfusion continues to predict outcome in endovascular treatment, so the possibility of direct triage to the angiography suite is potentially desirable. Small series of patients have examined “one stop imaging” with a direct-to-angiography suite for imaging with the flat panel detector computed tomography and decision making about intravenous alteplase and thrombectomy taking place there, with the goal of avoiding time in a separate computed tomography scan 114115. If the quality of the flat panel detector computed tomography to detect hemorrhage, ischemic changes, and LVO is confirmed, this might be an option to significantly reduce time at endovascular capable centers.…”

In‐hospital acute stroke workflow in acute stroke – Systems‐based approaches

“…DAN procedures may be difficult to generalize at other stroke centres due to haemodynamic instability of stroke patients which may mandate ED management, and transport delays to angiography which may warrant a repeat CT to monitor haemorrhagic transformation and infarct growth 16 . Nonetheless, several studies have highlighted the feasibility, safety and efficacy of DAN procedures, 65‐68 with a case‐control study by Requena et al 65 highlighting lower rates of haemorrhagic transformation and improved 90‐day functional outcomes in comparison with conventional workflow.…”

Evolution of Stroke Thrombectomy Techniques to Optimize First-Pass Complete Reperfusion

“…[60][61][62] Fast first-pass complete reperfusion, which is the focus of this review article, remains a cornerstone for successful stroke treatment. However, nowadays improving prehospital stroke management and intrahospital workflows (e.g., bypassing the CT scanner to get the patient faster to the angiography table: the so-called one-stop management) 63,64 yields an even greater potential for improving patient outcomes.…”