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London, United Kingdom 2013 Poster Session Blue Cerebrovasc Dis 2013; 35 (suppl 3)1-854 679 627 Acute stroke: emergency management, stroke units and complications Estimated stroke candidates for intravenous rt-PA therapy with extension of therapeutic time window M. Koga1, H. Yamagami2, K. Nagatsuka3, K. Minematsu4, K. Toyoda5 National Cerebral and Cardiovascular Center, Suita, JAPAN1, National Cerebral and Cardiovas-cular Center, Suita, JAPAN2, National Cerebral and Cardiovascular Center, Suita, JAPAN3, National Cerebral and Cardiovascular Center, Suita, JAPAN4, National Cerebral and Cardiovascular Center, Suita, JAPAN5 Background and Purpose: The ECASS 3 revealed the safety and efficacy of intravenous alteplase (rt-PA) therapy 3 to 4.5 h after ischemic stroke onset. An updated meta-analysis including the IST 3 suggested a significant increase of independent patients within 6 h. Alteplase was approved up to 4.5 h at the end of August 2012 in Japan. This study was aimed to assess estimated candidates for rt-PA with time window extension and their characteristics. Methods: We reviewed consecutive ischemic stroke patients who received rt-PA (3-h group), those who arrived within 3.5 h of onset (with assuming 1 h for door to needle) without receiving rt-PA and fulfilled the inclusion and exclusion criteria for rt-PA except the time window (4.5-h group) and those who arrived within 5 h without rt-PA and fulfilled the criteria except the time window (6-h group) from our prospective stroke database between January 2011 and August 2012. Results: Four hundred thirteen patients arrived at our hospital within 5 h of onset. Of them, 101 patients were assigned to the 3-h group, 28 to the 4.5-h group and 51 to the 6-h group. As com-pared to patients in the 3-h group, both those in the 4.5-h and 6-h groups more frequently suffered without the witness to stroke onset (64% for 4.5-h and 65% for 6-h vs. 38% for 3-h; p=0.005 and p<0.001, respectively), less commonly had cardioembolic stroke (46% and 45% vs. 67%; p=0.043 and p=0.008, respectively) and more frequently had vertebrobasilar stroke (36% and 31% vs. 16%; p=0.020 and p=0.027, respectively). There were no differences in sex, age, vascular risk factors, co-morbidities and initial NIHSS between the 4.5-h group/6-h group and the 3-h group. Conclusions: Extensions of the therapeutic time window up to 4.5 h/6 h may enable us to treat 1.3-fold/1.5-fold patients with rt-PA. Additional candidates are more likely to suffer without the wit-ness, and have less cardioembolic stroke and more vertebrobasilar stroke than those within 3 h. 628 Acute stroke: emergency management, stroke units and complications Reducing call to needle time: the stroke 90 project M. KRISHNAN1, M. Kapoor2, J. Kendall3, R. A. Bosnell4, J. Pearson5, R. Hardie6, J. Stevens7, N Baldwin8 Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM1, Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM2, Department of Emergency Medicine, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM3, Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM4, Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM5, Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM6, Department of Neurology, Frenchay Hos-pital, North Bristol NHS Trust, Bristol, UNITED KINGDOM7, Department of Neurology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UNITED KINGDOM8 Background: The benefit of intravenous thrombolysis in acute ischaemic stroke is well established. Rate of throm-bolysis in our institution is 19% of all ischaemic strokes. However, its efficacy rapidly declines from an Odd’s ratio of 2.3 at 60 minutes after the stroke onset to 1.7 at 180 minutes. The concept of ‘time is brain’ remains a major challenge. The aim of this study is to reduce the door to needle times to less than 90 minutes. Method: Review of our existing hyperacute pathway identified two potential points to improve our treatment time. For FAST positive patients, we instituted a protocol for direct admission to the CT scanner and a telephone pre-alert by the paramedics using a structured data form. Patients are assessed in the CT unit by the acute stroke team and eligible patients are thrombolysed without delay. Regular review meetings ensure that quality of care is not reduced by the speed of assessment. Results: Our data prior to ‘direct to CT’ reveals a mean door to CT time of 26.83 minutes (range of 3 to 105) and a door to needle time of 73.49 minutes (March 2011 to January 2012). Since the introduction of ‘direct to CT’ protocol, these times have been reduced to 10.1 and 39.65 minutes respectively from data obtained from 20 consecutive patients (June/July 2012). We went ahead to introduce the pre-alert system, which further improved our treatment times to a median of 4 minutes (door to CT) and 29 minutes (door to needle), with regular review of the pathway to ensure patient safety. There remains significant inter-patient variation, which is mainly related to out-of –hour presenta-tions where the stroke-network telemedicine time adds to the delay. Conclusion: This study shows that continuous audit and regular review of performance of the whole hyperacute pathway can reduce the delay from stroke onset to thrombolysis, which in turn results in better out-come for patients.


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