Bringing Down the Door-to-needle Time: Patient Thrombolysed in 6 Minutes—A Case Report

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Authors

Ankur Verma, MBBS, MEM¹; Sanjay Jaiswal, MBBS, MEM¹

Perm J 2021;25:20.239

https://doi.org/10.7812/TPP/20.239

E-pub: 02/24/2021

Introduction: It has been clearly established that thrombolysis using recombinant tissue plasminogen activator is strongly beneficial for acute stroke patients. The sensitivity of brain tissue to ischemia causes this time dependence on the effectiveness of recombinant tissue plasminogen activator. Early recognition of stroke and activation of a stroke alert/code are imperative to treat acute stroke patients effectively and to realize positive outcomes.

Case Presentation: A 68-year-old man with right-sided weakness arrived at our emergency room and was thrombolysed in 6 minutes from time of arrival, after ruling out all contraindications.

Conclusion: The case and our rapid thrombolysis protocol that helped in achieving the 6-minute door-to-needle time are described. A structured protocol is recommended to reduce door-to-needle times for thrombolysis in acute ischemic stroke.

INTRODUCTION

Approximately 11% of deaths around the world are the result of stroke, making it the second most common cause of death.1 In India alone, 1.44 to 1.64 million new cases of acute stroke are reported every year,2 and the 30-day case fatality ranges from 18% to 41%.3 Recently, there has been a lot of emphasis on stroke prevention and early management protocols, and this has led to a decrease in mortality rates worldwide.4

One of the major spokes of stroke care includes early initiation of thrombolytic therapy. It has been clearly established that thrombolysis using recombinant tissue plasminogen activator (rTPA) is strongly beneficial for acute stroke patients.5 Studies have shown that for every 15-minute reduction in door-to-needle time, there is a 5% lower odds of risk-adjusted inhospital mortality.6 We describe a case with a 6-minute door-to-needle time and provide an overview of our Rapid Thrombolysis Protocol.

CASE REPORT

A 68-year-old hypertensive man (being treated for hypertension) was brought to our emergency department (ED) with a sudden onset of right-sided weakness and inability to speak 30 minutes before arrival. On arrival, the patient had a pulse of 79/minute, a blood pressure of 150/90 mmHg, a respiratory rate of 20/minute, a serum random sugar level of 172 mg/dL, and he was saturating at 100% on room air. On examination, the patient was aphasic, had left-sided gaze preference, and had right-sided dense hemiplegia with facial involvement, with complete sensory loss of the right half of his body. He had an initial National Institutes of Health Stroke score of 26. A stroke code was announced and the patient was immediately sent for computed tomography (CT) of the brain. During the CT scan, the family was counseled regarding the patient’s condition and diagnosis, and the probable need for thrombolysis. Consent for the same was acquired immediately. The patient had no contraindications for thrombolysis. Because the CT scan was not suggestive of any intracranial hemorrhage, thrombolysis with rTPA was started while the patient was in the CT scanner: a 7-mg intravenous bolus followed by 63 mg over 1 hour. This was achieved in 6 minutes from the time of arrival (36 minutes from time of onset). With the ongoing thrombolytic infusion, the patient underwent CT angiography of the brain, which revealed a thrombosed distal M1 segment of the left middle cerebral artery (Figure 1). The patient was moved back to the ED, and admission to the stroke Intensive Care Unit was initiated. The patient achieved remarkable neurological recovery in 2 hours (National Institutes of Health Stroke Scale score of 5). For secondary prevention, the patient was kept on conservative management with 150 mg acetylsalicylic acid and 80 mg atorvastatin. Repeat CT angiography of the brain on day 5 showed good flow in the bilateral middle cerebral arteries, including the M1 segment of the left middle cerebral artery (Figure 2). The patient was discharged on day 6 with normal speech and mild hemiparesis, and a National Institutes of Health Stroke Scale score of 1. The patient was advised neurological follow-up and outpatient physiotherapy.

Figure 1. Computed tomographic angiography of the brain revealed a thrombosed distal M1 segment of the left middle cerebral artery with no flow (arrow).

Figure 2. Repeat computed tomographic angiography of the brain on day 5 shows good flow in the bilateral middle cerebral arteries, including the M1 segment of the left middle cerebral artery (arrow).

Rapid Thrombolysis Protocol

Our inhospital protocol (Table 2) was created with the aim of reducing our door-to-needle times in acute ischemic stroke patients. Patients arriving at the triage area with any symptoms of stroke are brought to the attention of the senior ED physician by a triage nurse. If we have prehospital information regarding a stroke patient arriving, a green corridor is established from triage to CT/magnetic resonance imaging. Counseling of the family is done regarding the condition and diagnosis, and probable need for thrombolysis by the doctor/emergency medical technician in the ambulance, and live locations are shared with the ED team. The vital signs of the patient are recorded by a trained triage nurse while physicians quickly evaluate the patient in the triage room itself. On confirmation of clinical stroke, a stroke code is announced by dialing the emergency code.

The calls are received by the neurologist on call, radiology, the laboratory, and medical administration. The patient is sent immediately to radiology for brain CT or magnetic resonance imaging (diffusion weighted and fluid attenuation inversion recovery). Magnetic resonance image is done for patients who have wakeup stroke, when the exact time of onset is not known, or when symptoms and signs are vague. If magnetic resonance imaging is contraindicated and a radiological diagnosis is required, then a CT perfusion study is completed. While the patient is undergoing CT, the family is counseled regarding the patient’s clinical diagnosis and condition, and probable need for thrombolysis; consent for the same is obtained. All contraindications are ruled out during the scan. rTPA is brought to the radiology department by an ED nurse to save time in case thrombolysis is required. If the CT scan is normal and clinical diagnosis of ischemic stroke is established, the patient is given a bolus dose followed by infusion over 1 hour. All stroke blood samples are sent before giving the bolus drug. The neurologist is then consulted regarding the need for additional CT angiography. If required, the infusion is continued in the CT scanner. The patient is then sent back to the ED, where an ED physician and nurse monitor his or her hemodynamic values and neurological recovery/worsening. The neurology team meets to determine whether there is a need for mechanical thrombectomy. The patient is then sent to the stroke Intensive Care Unit.

DISCUSSION

Until recently, the recommended door-to-needle time for acute ischemic stroke is 60 minutes or less.7 We suggest that a structured protocol can greatly reduce door-to-needle times. It is well established that early thrombolysis can achieve much better outcomes for ischemic stroke patients.8 The sensitivity of brain tissue to ischemia causes this time dependence on the effectiveness of rTPA.9 Thus, it is imperative that institutions have a streamlined, robust stroke protocol.

Recognition of stroke begins in the prehospital setup. Paramedics who are transporting patients via ambulance should be trained to recognize stroke and to transfer patients to the appropriate center.10 Triage nurses play an equally important role in the early recognition of stroke when patients arrive at the ED. Nurse training is paramount for a successful stroke protocol. Early recognition by nurses leads to early diagnosis and shorter door-to-needle times.11

The use of a stroke code alert system has been shown to improve time to diagnosis and treatment, and to reduce intravenous rTPA door-to-needle times.12 Worldwide studies have shown there are multiple inhospital delays when delivering rTPA to stroke patients.13 There is a lot of scope for reducing door-to-needle times to improve outcomes. Through regular audits and protocol checks, many of the delays that hamper timely thrombolysis may be identified and rectified.

A robust stroke program requires a significant volume of stroke patients arriving at the ED, trained paramedics and triage nurses, and trained emergency medicine physicians and inhouse neurologists available 24/7. In addition, the radiology department, laboratory, and catheter suite for thrombectomies must be available, along with a stroke Intensive Care Unit for postthrombolytic care. Last, there should be regular data collection and discussions regarding all cases to recognize delays and revise any protocols if required.

Although our report highlights the feasibility of achieving such short door-to-needle times, it may not always be possible because there may be factors that delay thrombolysis, such as a delay in receiving family consent, the family wanting a second opinion, a determination of hypertension (which needs to be controlled prior to thrombolysis), incomplete drug history, and so on.

Our case does not highlight the target door-to-needle time because it is not possible for every patient. We do recommend that a structured protocol, such as our Rapid Thrombolysis Protocol, can reduce mean and median door-to-needle times substantially (to much less than 60 minutes) for acute ischemic stroke.

Table 1. Patient timeline for relevant past medical history and interventions, including relevant personal, family, and psychosocial history; important past interventions; outcomes; and follow-up.^a

^a Include genetic information if available.

CT = computed tomography; CTA = computed tomographic angiography; EKG = electrocardiogram; INR = international normalized ratio; OPD = out patient department.

Table 2. Rapid Thrombolysis Protocol checklist. CT = computed tomography; ED = emergency department; EMT = emergency medical technician; MRI = magnetic resonance imaging.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Author Affiliations

1Department of Emergency Medicine, Max Super Specialty Hospital, New Delhi, India

Corresponding Author

Ankur Verma, MBBS, MEM ()

Author Contributions

Ankur Verma, MBBS, MEM, is the principal author and contributed to the conception, literature review, and design of the manuscript. Sanjay Jaiswal, MBBS, MEM, contributed to drafting, discussion, and critical revision of the manuscript. The authors did not have any third-party contributions to design, data collection, data analysis, or manuscript preparation.

Disclaimer

The views expressed in the article are the authors’ own and not an official position of the institution.

Funding

No funding was received for this case report.

References

1. Towfighi A, Saver JL. Stroke declines from third to fourth leading cause of death in the United States: Historical perspective and challenges ahead. Stroke 2011 Aug;42(8):2351–5. DOI: https://doi.org/10.1161/STROKEAHA.111.621904, PMID:21778445

2. Murthy J. Thrombolysis for stroke in India: Miles to go . . . . Neurol India 2007 Jan–Mar;55(1):3–5. DOI: https://doi.org/10.4103/0028-3886.30415.

3. Dalal PM, Malik S, Bhattacharjee M, et al Population-based stroke survey in Mumbai, India: Incidence and 28-day case fatality. Neuroepidemiology 2008 Oct;31(4):254–61. DOI: https://doi.org/10.1159/000165364, PMID:18931521

4. Jauch EC, Saver JL, Adams HP Jr, et al Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013 Mar;44(3):870–947. DOI: https://doi.org/10.1161/STR.0b013e318284056a, PMID:23370205

5. Roth JM. Recombinant tissue plasminogen activator for the treatment of acute ischemic stroke. SAVE Proc 2011 Jul;24(3):257–9. DOI: https://doi.org/10.1080/08998280.2011.11928729, PMID:21738304

6. Fonarow GC, Smith EE, Saver JL, et al Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: Patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation 2011 Feb;123(7):750–8. DOI: https://doi.org/10.1161/CIRCULATIONAHA.110.974675, PMID:21311083

7. Fonarow GC, Smith EE, Saver JL, et al Improving door-to-needle times in acute ischemic stroke: The design and rationale for the American Heart Association/American Stroke Association’s target: Stroke initiative. Stroke 2011 Oct;42(10):2983–9. DOI: https://doi.org/10.1161/STROKEAHA.111.621342, PMID:21885841

8. Lees KR, Bluhmki E, von Kummer R, et al Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May;375(9727):1695–703. DOI: https://doi.org/10.1016/S0140-6736(10)60491-6, PMID:20472172

9. Marler JR, Tilley BC, Lu M, et al Early stroke treatment associated with better outcome: The NINDS rt-PA stroke study. Neurology 2000 Dec;55(11):1649–55. DOI: https://doi.org/10.1212/wnl.55.11.1649, PMID:11113218

10. Brice JH, Evenson KR, Lellis JC, et al Emergency medical services education, community outreach, and protocols for stroke and chest pain in North Carolina. Prehosp Emerg Care 2008 Jul–Sep;12(3):366–71. DOI: https://doi.org/10.1080/10903120802100100, PMID:18584506

11. Middleton S, Grimley R, Alexandrov AW. Triage, treatment, and transfer: Evidence-based clinical practice recommendations and models of nursing care for the first 72 hours of admission to hospital for acute stroke. Stroke 2015 Feb;46(2):18–25. DOI: https://doi.org/10.1161/strokeaha.114.006139.

12. Meretoja A, Strbian D, Mustanoja S, et al Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012 Jul;79(4):306–13. DOI: https://doi.org/10.1212/WNL.0b013e31825d6011, PMID:22622858

13. Klingner CM, Brodoehl S, Hohenstein C, et al A case with 7 min door-to-needle-time and an outline of ultrarapid stroke management. Brain Disord Ther 2014 Nov;4(1):153–6. DOI: https://doi.org/10.4172/2168-975X.1000153

Keywords: ischemia, stroke, thrombolysis