Telestroke Neurologists May Have Longer Nonenhanced CT-to-CTA Times, Compared With Bedside Neurologists

LOS ANGELES—Among patients with acute ischemic stroke due to large-vessel occlusion, average time from nonenhanced CT (NECT) to CT angiogram (CTA) was significantly longer for patients evaluated at nonendovascular stroke centers by telestroke neurologists, compared with the average time for patients evaluated at endovascular stroke centers by bedside neurologists, according to research presented at the International Stroke Conference 2018.

“Importantly, it may be that the delays at facilities covered by teleneurologists are due to radiology policies and procedures.… Telestroke neurologists should work with emergency department physicians and CT personnel to ensure that patients with suspected large-vessel occlusions have a CTA performed immediately after completion of the NECT,” said Andrew W. Asimos, MD, Medical Director of the Carolina Stroke Network of Carolinas Healthcare System in Charlotte, North Carolina.

Andrew W. Aimos, MD

“These data suggest that steps should be taken to ensure that NECT-to-CTA times receive the same attention as door-to-needle IV t-PA times in assessing overall telestroke neurologist process performance.”

The 2015 American Heart Association/American Stroke Association stroke management guidelines strongly recommend that if endovascular therapy is considered, CTA should be included in the initial imaging evaluation. A prompt CTA can expedite the identification and transfer of patients with large-vessel occlusion for endovascular treatment, said Dr. Asimos.

Telestroke Neurologists vs Bedside Neurologists

Telestroke neurologists mainly focus on achieving quick door-to-needle IV t-PA times, rather than prompt CTA performance times, however. As a result, the researchers hypothesized that the NECT-to-CTA time interval for patients with large-vessel occlusion would be significantly longer at nonendovascular stroke centers using telestroke neurologists than at endovascular stroke centers with bedside neurologists.

To test this hypothesis, the researchers conducted a retrospective analysis. They compared the NECT–to-CTA time performance interval for consecutive patients with large-vessel occlusion who initially presented to any of 23 hospitals or freestanding emergency departments in a large healthcare system’s stroke network database and were candidates for endovascular treatment.

Over a seven-month period, researchers identified 71 cases of large-vessel occlusion in which patients initially presented to one of 21 nonendovascular stroke centers covered by telestroke neurologists and 62 cases in which patients presented to one of two endovascular stroke centers covered by bedside neurologists. After removing the outliers (ie, those NECT-to-CTA times greater than the 95th percentile for endovascular stroke center cases and greater than the 90th percentile for nonendovascular stroke center cases), researchers retained 64 cases from nonendovascular stroke centers and 59 cases from endovascular stroke centers.

In all, 48.4% of patients evaluated at nonendovascular stroke centers and 45.8% of patients evaluated at endovascular stroke centers were female.

NECT-to-CTA Times Were Longer at Nonendovascular Stroke Centers

Overall, patients evaluated at nonendovascular stroke centers had significantly longer NECT-to-CTA performance times, compared with those examined at endovascular stroke centers. The mean NECT–to-CTA time interval was 29.9 minutes for telestroke neurologists, compared with 10 minutes for bedside neurologists. It is unknown, however, what protocol limitations contributed to these longer NECT to CTA performance times at non-endovascular stroke centers, said the researchers.

“Our focus now is to ensure that a sensitive large-vessel occlusion screen is performed on all patients prior to going to CT. For patients that screen positive for a possible large-vessel occlusion, we advocate that a CTA be performed immediately after the NECT,” said Dr. Asimos.

—Erica Tricarico