Consistently Achieving Computed Tomography to Endovascular Recanalization <90 Minutes: Solutions and Innovations

Perspective:

The following are 10 points to remember about achieving computed tomography (CT) to endovascular recanalization <90 minutes:

1. Available data suggest that a delay in recanalization for acute large vessel ischemic stroke reduces the average absolute rate of a good outcome significantly.

2. The process of (CT) head to reperfusion within 60 minutes requires some key processes to be in place. These include the presence of an organized emergency team to evaluate and stabilize vitals, secure airway, register the patient into the hospital information system, make a complete but quick clinical assessment, understand the patient’s premorbid status, expectations of outcome, advance directives, contraindications to treatment (and participation in trials), and need for ventilation/anesthesia support.

3. A single person or a group of individuals from one discipline cannot achieve successful endovascular treatment of stroke consistently. Teams need to be divided into two key components: the stroke team and the endovascular team. The diagnosis and treatment are performed in parallel by members of both teams to maximize the use of limited time. Trust and teamwork are essential.

4. A quick and focused neurological examination is all that is needed especially in severe strokes because of large vessel occlusion to prevent delays in endovascular reperfusion.

5. Imaging protocol may include a noncontrast CT head and a multiphase CT angiography. It is important to optimize CT scan quality to be able to appreciate early ischemic changes.

6. CT angiography is needed for planning of the endovascular procedure. An analysis of the arch allows a precise determination of what kind of catheter would be needed to access the carotid. An evaluation of the carotid bifurcation can be used to determine where the balloon guide catheter should be placed. An assessment of the circle of Willis and tortuosity can be used to determine the need for a distal access catheter and length and size of the stentriever, and the possibility of using direct thrombus aspiration as the primary intervention.

7. A standardized approach for summarizing the natural history and known results of recent trials helps the consent process.

8. A standardized stroke kit that is ‘ready to go’ is helpful. A stroke table laid out with all the necessary materials such as cleaning solution, drapes, an 8F sheath, a balloon guide catheter, an inner catheter in a coaxial fashion to access the arch, a 021 microcather, and a stentriever is helpful.

9. Parallel processing, minimalist, and qualitative imaging approach, better organization of the angiography laboratory, and setting up the stroke kit results in the greatest time savings.

10. Finally, in the future, centralization of acute stroke care will be needed. Emergency Medical Services can then redirect patients with severe strokes to a comprehensive stroke center and minimize treatment delays.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging

Keywords: Neurologic Examination, Anesthesia, Advance Directives, Hospital Information Systems, Stroke, Endovascular Procedures, Emergency Medical Services, Thrombosis, Tomography, X-Ray Computed, Carotid Artery, Internal, Angiography, Circle of Willis


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