The Correlation Between Emergency Workflow And Clinical Outcomes In Patients With Acute Large Vascular Occlusive Stroke

Objective: To investigate the“working-time effect”on the process and outcomes of early EVT in patients with AIS-LVO of anterior circulation.Methods: The patients with AIS-LVO of anterior circulation who received EVT in the advanced stroke center of the First Affiliated Yijishan Hospital of Wannan Medical College between February 2019 and March 2021 were retrospectively included.The enrolled patients were divided into on-hour group and off-hour group according to their arrival time.Subgroup analysis was performed for patients admitted at night(22:00-07:59)and non-night(08:00-21:59)in the non-working hours group.The baseline characteristics,process time interval and 90-day modified Rankin Scale(m RS)score after EVT were collected.And the factors affecting diagnosis and treatment procedures and prognosis were analyzed.The primary outcome indicators was the m RS score at 90 days after EVT,and the secondary outcome indicators were recanalization of occluded vessel and symptomatic intracranial cerebral hemorrhage(s ICH).Results: A total of 303 patients [Mean age:(68.8±10.4)years] were included in this study,205(67.7%)cases in the off-hour group and 98(32.3%)cases in the on-hour group.There was no statistically significant difference in the 90-day m RS score between the off-hour group and the on-hour group(P=0.555),and there was no significant difference in time intervals between two groups,such as symptom oneset to door time(P=0.823),door to puncture time(P=0.244)and puncture to reperfusion time(P=0.847).The subgroup was setted in the off-hour group according to whether the patients were admitted at night or not.They were divided into night group(22:00-07:59)and non-night group(08:00-21:59).There were 49(23.9%)cases in the night group and 156(76.1%)cases in the non-night group.Similarly,there was no significant difference in 90-day m RS score between two groups(P=0.812).However,the time from symptom onset to doorl was significantly prolonged in the nighttime group(median time: 284(180,371)minutes vs.220(150,290)minutes,Z =-2.438,P=0.015),while there was no significant difference in the time from door to puncture and the time from puncture to recanalization(P= 0.180 and 0.236,respectively).However,the time from symptom oneset to hospital was significantly prolonged in the night group(284 minutes vs.220 minutes,P=0.015).Conclusion: No "working-hour effect" was found to affect EVT workflow and outcomes in patients with AIS-LVO of anterior circulation.However,patients admitted to hospital at night had significant pre-hospital delays.Objective: Door-in-door-out time(DIDO)in primary stroke centers is key performance indicator of prehospital delay in patients with acute ischemic cerebral infarction.To investigate the association between DIDO and clinical outcome of patients with acute large vessel occlusion stroke(ALVOS)of anterior circulation after early endovascular therapy(EVT).Methods: The patients with AIS-LVO of anterior circulation who received EVT in the advanced stroke center of the First Affiliated Yijishan Hospital of Wannan Medical College from February 2019 to December 2021.DIDO time was defined as the duration of time from arrival to referral at the primary stroke center,and the primary outcome was favorable clinical outcome,as evaluated by a modifified Rankin Scale score of 0 to 2 at 3months after EVT.Results: A total of 320 patients [aged(69.6±10.2)years] were enrolled.Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program early CT score were 14(11,18)and 8(7,9).Median DIDO time was 76minutes(50,120).DIDO time was not an independent risk factor for clinical outcomes in patients with EVT in the overall population,but it was in patients receiving early endovascular therapy(OTR≤300minutes)(OR=1.030,95%CI: 1.001-1.059,P=0.041).A According to the subject work characteristic curve,the DIDO cutoff of 74.5 minutes can be used as an important indicator of prehospital delay in referral to EVT for large vascular occlusion stroke.A multivariate analysis showed that DIDO ≤74.5 minutes emerged as an independent factor associated with favorable outcome(OR=3.084,95%CI: 1.738~5.473,P < 0.001).Door to computed tomography time(OR=1.393,95%CI: 1.212~1.601,P < 0.001)and computed tomography to transfer time(OR=1.386,95%CI: 1.220~1.575,P < 0.001)were factors associated with DIDO ≤74.5 minutes in a multivariate analysis in this time frame.Conclusion: In transferred patients undergoing EVT,DIDO has a signifificant impact on clinical outcome.DIDO can be used as an important quality control indicator to evaluate the referral process for patients with ALVOS.Objective: Previous studies have shown that delays in stroke emergency procedures reduce the proportion of stroke patients receiving EVT.Our aim is to identify new and modifiable delay factors.Methods: The patients with acute large vascular occlusive stroke who received EVT at two advanced stroke centers,the First Affiliated Yijishan Hospital of Wannan Medical College and Huangshan People’s Hospital from December 2020 to December 2021,were analyzed retrospectively.The patient and/or guardian are interviewed by a professional neurologist within 24 hours after EVT through a standardized questionnaire.The delay in emergency procedures was defined as the time(OPT)> 6 hours.OPT is defined as the time between the patient’s stroke symptoms witnessed(or the last observed normal time)and admission to hospital.The baseline data,process time,clinical outcome and other data of all enrolled patients were collected to analyze the factors affecting the emergency procedures and clinical outcome.The primary outcome was m RS Score 90 days after EVT,and the secondary outcome were malignant cerebral edema(MCE)and symptomatic intracranial hemorrhage(s ICH).Results: A total of 367 patients were enrolled.The number of patients stroke in thrombolectomy center was 14.Finally,353 patients with a mean age of(68.7±10.9)years were included,and 109 patients(30.9%)were observed to have delayed treatment.The National Institutes of Health Stroke Scale(NIHSS)score was 14(11,18)and the Alberta Stroke Program Early CT score was 9(8,10).The main modifiable risk factor for delayed emergency procedures was seeking post-onset help outside the emergency center(clinic vs.emergency center(OR=44.508,95%CI: 2.261-876.129,P=0.013);other helps vs.emergency center(OR=2.440,95%CI: 1.153-5.163,P=0.020)],arrival at a non-hospital facility after onset(OR=0.010,95%CI: 0.000-0.330,P=0.010),lack of awareness of stroke(OR=2.491,95%CI: 1.294 to 4.796,P=0.006),and delayed call 120 or unselected call 120(OR=2.988,95%CI: 1.387 to 6.437,P=0.005).Conclusion: The choice of patients after the onset of stroke,stroke awareness,and early call to emergency number are modifiable factors to reduce the delay of emergency procedures.Efforts should be made to increase the publicity of stroke knowledge,improve people’s stroke awareness,and make a faster and more correct choice after the occurrence of stroke.