Consistently achieving computed tomography to endovascular recanalization <90 minutes: solutions and innovations.

Data from IMS3 suggest that a 30-minute delay in recanalization reduces the average absolute rate of a good outcome by 11%. 1 Mazighi et al 3 have demonstrated a relationship between delays and increased mortality. A similar analysis from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) Study data set suggests a 38% relative reduction in good outcome by a 1 hour delay in recanalization. 2 Rate of cell death has been estimated to be ≈2 million neurons/min in M1 occlusion. 4 Currently in the United States, the mean time from symptom onset to groin puncture is 6 hours with an additional hour to achieve revascularization. 5 It is clear that we as a collective need to improve overall workflow in endovascular management of acute large vessel ischemic stroke. We have demonstrated that computed tomography (CT) head to reperfusion within 60 minutes is achievable. 6 However, the process of achieving this metric 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. Imaging needs to be geared up toward efficiency and rapid decision making. The key imaging components are rule out an intracra-nial bleed (and other intracranial conditions such as a tumor or subdural hemorrhage), identify that the patient has a small core of infarction and a proximal vessel occlusion on CT angi-ography. Other considerations may include anatomy (does the patient have aberrant anatomy or pathology that may influence endovascular access), presence of penumbra/collaterals. Intravenous tissue-type plasminogen activator (tPA) needs to be administered based on standard of care but without creating any delay in the effort toward achieving reperfusion. Assuming that the patient is suitable for the endovascular procedure (or an acute endovascular trial), the next steps include obtaining consent, getting the cath laboratory team together, organizing anesthesia if necessary, transporting the patient to the angiography suite, getting the angiography suite organized , having the patient prepared using standard antiseptic techniques, access the vascular system and the clot, and finally achieve optimal reperfusion. During this procedure, maintenance of the patient's vitals and use medications as necessary to hold the patient still should help expedite the workflow and not …