The Need For Speed: Consistently Achieving Arrival To Recanalization Times In 90 Minutes Or Less For Large Vessel Occlusion

Introduction: Since the treatment effect of mechanical thrombectomy (MT) is profoundly time-dependent, we created an optimized Comprehensive Stroke Center-Large Vessel Occlusion (CSC-LVO) protocol focusing on three key steps: early vessel imaging on all code stroke patients, standardizing the MT procedure, and integrating a team of stroke-dedicated advanced practice clinicians (APCs) to manage patients across the continuum of initial hospital care. Methods: All direct to CSC (“mothership”) LVO patients treated during the following time periods (Epochs) were retrospectively reviewed: 1/1/2015 to 6/30/2015 (Pre-optimization); 1/1/2016 to 6/30/2016 (Early Vessel Imaging and MT standardization) and 1/1/2017 to 6/30/2017 (Early Vessel Imaging, MT standardization, APC integration). Epochs were separated by 6 months to minimize any “ramp-up” effect. We included all patients who presented with large vessel occlusion stroke (ICA, M1, Basilar), within six hours from symptom onset, and with an NIHSS of 6 or higher. During Epoch 3, APCs were available for 12h/day and 7 days a week. For all cases, the neurointerventional team was activated only after the CTA confirmed large vessel occlusion. To measure efficiency of initial hospital processes, we compared CSC door to CT, door to CTA, door to IV t-PA, door to groin puncture, and door to recanalization across time Epochs. Results: All results are summarized in the table below and there was a marked decrease in median time from CSC arrival to recanalization from 186 to 100 minutes. Within Epoch 3, when APCs were in-house (n=29/44 or 70% of cases), the median [IQR] Door to t-PA, door to groin puncture, and door to recanalization times were lowest 27 [23-31], 53 [42-73], and 86 [72-118] minutes, respectively. Conclusions: A CSC-LVO protocol including early vessel imaging, procedural standardization, and integrating a team of stroke-dedicated APCs enables CSCs to achieve median door to recanalization times in less than 90 minutes.