Beating the Clock: Time Delays to Thrombolytic Therapy with Advanced Imaging and Impact of Optimized Workflow

Background: The effectiveness of intravenous tissue plasminogen activator in the management of acute ischemic strokes diminishes significantly with time. Advanced computed tomography (CT) imaging can be helpful to identify candidates for neurointerventional procedures. We have successfully used a 320-slice Toshiba volume CT scanner since mid-2008. Other centers have forgone advanced imaging because of concerns of time delay. This study is to assess the time delay while using this scanner compared with our 64-slice scanner. Methods: Treatment times of patients scanned with advanced imaging (CT head, dynamic CT angiography, and whole brain perfusion-group A) and patients scanned in a 64-slice scanner (CT head and traditional CT angiogram-group B) were compared. Two groups of stroke patients from November-March 2009-2010 (group 1) and 2012-2013 (group 2) were audited to assess temporal improvement. Multiple timing variables were analyzed. Results: One hundred fifty-three cases from 2009/10 and 192 cases from 2012/13 were analyzed. The median door-to-needle time (DNT) for group 1A and group 2A was 57 minutes and 47 minutes, respectively. The median DNT for group 1B and group 2B was 54 minutes and 49 minutes, respectively. Decrease in the overall DNT with group A can be attributed to the "streamlining'' of the stroke code process. There was no difference in the DNT for patients who presented during working hours versus those who presented during nonworking hours. Conclusions: With adequate experience and training, advanced stroke imaging with whole brain perfusion/dynamic CT angiography can be performed with treatment times that are comparable with traditional CT scanning.