Citations

Background: Telestroke care has become a vital feature of expert stroke care for rural hospitals in recent years. The Telemedicine for Arizona Rural Residents (STARR) program was developed in 2006 by the Mayo Clinic in Arizona in order to provide stroke expertise across the region. However, little data currently exists to determine efficacy of telestroke programs on accepted stroke care metrics, such as door-to-needle times. Hypothesis: Participation of spoke sites in a telestroke program improves stroke care over time, as defined by currently-accepted metrics, such as door-to-needle time. Methods: A retrospective analysis was performed on the telestroke database from Mayo Clinic, Arizona, between the years of 2011 to 2018. Patients who received IV-tPA for an acute ischemic stroke were included in the analysis. Patients who did not have radiographic or clinical symptoms of an acute ischemic stroke, as well as those who did not receive IV-tPA, were excluded from the analysis. Univariate linear regression was performed to look for associations between variables and defined outcomes. Results: 565 patients were identified who received IV-tPA via telestroke consultation and met inclusion criteria between 2011 to 2018. Average last known normal (LKN) to needle time decreased across all sites from 176 minutes in 2011 to 147 minutes in 2018, with univariate linear regression showing a trend of decreased time averaging 3 minutes per year, which was statistically significant (p = 0.0084). Average door-to-needle times decreased from 112 minutes in 2011 to 81 minutes in 2018, with univariate linear regression modeling showing a decreasing trend of 3.5 minutes on average per year (p < 0.001). Conclusions: Telestroke participation may be associated with improved stroke care metrics over time, with our analysis illustrating improved LKN-to-needle and door-to-needle times among participating spoke sites.

Mechanical thrombectomy (MT) is the standard of care for patients who present with an acute ischemic stroke within 6 hours of symptom onset, and up to 24 hours in appropriately selected patients. However, optimal postoperative management of these patients remains uncertain, especially with regard to blood pressure control. To review the existing literature to define potential blood pressure goals in the immediate postoperative period in patients who undergo MT for acute ischemic stroke. The topic was defined through a clinical scenario and the subsequent development of a targeted clinical question. A literature search was performed, with relevant articles selected, one of which, a prospective observational study, was critically appraised. Participants included neurology residents and consultants, a medical librarian, clinical epidemiologists, as well as content experts from vascular neurology and interventional neuroradiology. Permissive hypertension (defined as <220/120 or <180/105 mm Hg as per the American Heart Association/American Stroke Association guidelines) may be harmful in the postoperative period following MT, especially in patients who were successfully recanalized. Moderate blood pressure control (<160/90) was found to be a predictor of improved 3-month mortality on multivariable logistic regression analysis in patients who sustained successful reperfusion [odds ratio (OR), 0.08; 95% confidence interval (CI), 0.01-0.054; P=0.01]. A 10 mm Hg increase in systolic blood pressure was found to result in a lower OR of having a favorable 3-month functional independence (OR, 0.70; 95% CI, 0.56-0.85; P=0.001) as well as higher rates of 3-month mortality (OR, 1.49; 95% CI, 1.18-1.88; P=0.001). Blood pressure goals in the immediate postoperative period in patients who undergo MT should differ than those who do not undergo MT, with data suggesting that lower blood pressure than permissive hypertension may be related to improved outcomes, especially in cases of successful reperfusion. However, current data are derived from observational studies; further studies, preferably in the form of randomized-controlled trials, are needed to further clarify the relationship between postoperative blood pressures and outcomes in this patient population.