What is the outcome of Door-to-needle Time within 60minutes for acute ischemic stroke patients treat with t-PA?

Chi-Ching Chen1, Hui-Fen Huang1, Yu-Ling Hung2, Yu-Yun Hsu4, Han-Jung Lee4, Chun-Hung Chen3,4

1Department of Nursing, Kaohsiung medical University Hospital, Kaohsiung medical University, Kaohsiung, Taiwan 2Department of Nursing, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung medical University, Kaohsiung, Taiwan 3Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan 4Department of Neurology, Kaohsiung medical University Hospital, Kaohsiung medical University, Kaohsiung, Taiwan

Table2. Clinical outcome between DTN with/without 60 minutes of acute ischemic stroke patients DTN(n) ≦1hr(n=40) ＞ 1hr(n=43) P-valueO to N(min) 114.7±37.74 141.23±29.84 0.001 DTN(min) 45.28±10.22 91.09±22.98 0.000 △NIHSS 5.68±6.59 4.28±8.26 0.400 Days(admission) 15.83±9.07 15.4±8.36 0.823 ICH 11 9 0.484 SICH 3 4 0.768 Mortality 0 2 0.167 Spend(NT) 250952.1±154242.5 257895.3±221704.5 0.870 post1mRS 0-2 14 13 0.643 post3mRS 0-2 16 13 0.392 post6mRS 0-2 16 15 0.558 O to N: onset-to-needle timeSICH: symptomatic intra-cranial hemorrhage

BackgroundThe good outcome of intravenous tissue-type plasminogen activator (t-PA) in acute ischemic stroke (AIS) patients are time-dependent. Recent many stroke guidelines recommend door-to-needle time (DTN) must be within 60 minutes for AIS patients treated with t-PA. The aim of our study was to evaluate the clinical outcome associated with DTN time 60 minutes.≦

MethodsDuring 4-year study period (2010~2013), we enrolled 69 acute ischemic stroke patients treated with intravenous tissue plasminogen activator (iv-tPA) within 3 hours after symptom onset. Thirty-four patients administrated iv-tPA within 1 hour, and the other (35 patients) were treated more than 1 hour. Data collected were patients’ characteristics, tPA dosage, time points (stroke symptom onset, presentation to ED, neuroimaging and thrombolysis), clinical outcome (90th days modified Rankin Scale (mRS), change of National Institute of Health Stroke Scale (NIHSS) at discharge, intracerebral hemorrhage (ICH) and death during admission), length of admission (LOA), and hospital cost. admission).

ResultsAmong 83 patients, only 40 (48.2%) DTN time was 60 ≦minutes. Patient demographic factors, characteristics, clinical outcome and 30, 90,180-day mRS were no significant different when compared with and without DTN times 60 minutes. The mean time of DTN 60 minutes ≦ ≦group was shorter (45.28 ±10.22 vs 91.09±22.98, p ＜0.0001), and the same result was found in mean time of onset-to-needle (OTN) (114.7±37.74 vs 141.23±29.84, p=0.001).

ConclusionsDespite the guidelines recommend the rate of DTN time ≦60 minutes must be 50% at least in AIS patient treat with t-PA. It only near one-half of patient achieved this target over the past 4 years in our hospital. Our data cannot reveal significant good outcome for AIS patient treat with t-PA within 60 minutes. But, it is only a preliminary result of our study, we need more case number and longer period of observation time can prove the benefit of shortening DTN time for AIS patients.Reference1.Gregg C. Fonarow, Eric E. Smith, Jeffrey L. Saver, et. 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;123:750-758.2.Greg g C . Fonarow, Xin Zhao, Eric E . Smith, et. Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative. JA M A. 2014;311(16):1632-1640.3.Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, 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 2013:1–8

Figure 1 Post-stroke 1mRS between DTN with/without 60 minutes

Figure 2 Post-stroke 3mRS between DTN with/without 60 minutes

Figure 3 Post-stroke 6mRS between DTN with/without 60 minutes

Table 1. Characteristics of all acute ischemic stroke patients DTN(n) ≦1hr(n=40) ＞ 1hr(n=43) P-valueAge(year) 62.35±14.06 67.84±12.19 0.061 Gender(F/M) 15/25 16/27 0.978 Dosage mg/kg 0.82±0.1 0.79±0.1 0.218 Hypertension 30 31 0.764 Diabetes 17 10 0.061 Previons CVA / TIA 10 7 0.325 Dyalipidemia 26 30 0.643 Atrial fibrillation 12 15 0.635 Heart disease 5 5 0.903 O to ER(min) 65.25±41.04 41.88±36.15 0.868 NIHSS (Admission) 13.65±5.6 13.23±5.36 0.730 DTN: door-to-needle timeO to ER: onset-to-ERNIHSS: National Institute of Health Stroke Scale