Systematic CT perfusion acquisition in acute stroke increases vascular occlusion detection and thrombectomy rates

BackgroundIn patients with stroke, current guidelines recommend non-invasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols.MethodsFrom April to October 2020 all patients admitted with a suspected acute ischemic stroke underwent urgent non-contrast CT, CTA and CTP and were treated accordingly. Hypoperfusion areas defined by time-to-maximum of the tissue residue function (Tmax) >6 s, congruent with the clinical symptoms and a vascular territory, were considered VO (CTP-VO). In addition, two experienced neuroradiologists blinded to CTP but not to clinical symptoms retrospectively evaluated non-contrast CT and CTA to identify intracranial VO (CTA-VO).ResultsOf the 338 patients included in the analysis, 157 (46.5%) presented with CTP-VO (median Tmax >6s: 73 (29–127) mL). CTA-VO was identified in 83 (24.5%) of the cases. Overall CTA-VO sensitivity for the detection of CTP-VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with increased CTA-VO detection (OR 1.03; 95% CI 1.02 to 1.04). EVT was performed in 103 patients (30.5%; Tmax >6s: 102 (63–160) mL), representing 65.6% of all CTP-VO. Overall CTA-VO sensitivity for the detection of EVT-VO was 69.9% and specificity was 95.3%. Among patients who received EVT, the rate of false negative CTA-VO was 30.1% (Tmax >6s: 69 (46–99.5) mL).ConclusionSystematically including CTP in acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.

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Abstract 1122‐000034: Systematic CT‐Perfusion acquisition in All Suspected Stroke Patients Increases Vascular Occlusion Detection and Thrombectomy Rates

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000034 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Marta Olive‐Gadea ◽

Manuel Requena ◽

Facundo Diaz ◽

Alvaro Garcia‐Tornel ◽

Marta Rubiera ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Symptoms ◽

Ct Perfusion ◽

False Negative ◽

False Negative Rate ◽

Vascular Occlusion ◽

Stroke Patients ◽

Imaging Protocols ◽

The Impact

Introduction : In acute ischemic stroke patients, current guidelines recommend noninvasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols on VO diagnosis and EVT rates. Methods : We included patients with a suspected acute ischemic stroke that underwent urgent non‐contrast CT, CTA and CTP from April to October 2020. Hypoperfusion areas defined by Tmax>6s delay (RAPID software), congruent with the clinical symptoms and a vascular territory, were considered due to a VO (CTP‐VO). Cases in which mechanical thrombectomy was performed were defined as therapeutically relevant VO (EVT‐VO). For patients that received EVT, site of VO according to digital subtraction angiography was recorded. Two experienced neuroradiologists blinded to CTP but not to clinical symptoms, retrospectively evaluated NCCT and CTA to identify intracranial VO (CTA‐VO). We analyzed CTA‐VO sensitivity and specificity at detecting CTP‐VO and EVT‐VO respecitvely. We performed a logistic regression to test the association of Tmax>6s volumes with CTA‐VO identification and indication of EVT. Results : Of the 338 patients included in the analysis, 157 (46.5%) presented a CTP‐VO, (median Tmax>6s: 73 [29‐127] ml). CTA‐VO was identified in 83 (24.5%) of the cases. Overall CTA‐VO sensitivity for the detection of CTP‐VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with an increased CTA‐VO detection, with an odds ratio of 1.03 (95% confidence interval 1.02‐1.04) (figure). DSA was indicated in 107 patients; in 4 of them no EVT was attempted due to recanalization or a too distal VO in the first angiographic run. EVT was performed in 103 patients (30.5%. Tmax>6s: 102 [63‐160] ml), representing 65.6% of all CTP‐VO. Overall CTA‐VO sensitivity for the detection of EVT‐VO was 69.9%. The CTA‐VO sensitivity for detecting patients with indication of EVT according to clinical guidelines was as follows: 91.7% for ICA occlusions and 84.4% for M1‐MCA occlusions. For all other occlusion sites that received EVT, the CTA‐VO sensitivity was 36.1%. The overall specificity was 95.3%. Among patients who received EVT, CTA‐VO was not detected in 31 cases, resulting in a false negative rate of 30.1%. False negative CTA‐VO cases had lower Tmax>6s volumes (69[46‐99.5] vs 126[84‐169.5]ml, p<0.001) and lower NIHSS (13[8.5‐16] vs 17[14‐21], p<0.001). Conclusions : Systematically including CTP perfusion in the acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.

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Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽

10.1161/strokeaha.120.031960 ◽

2021 ◽

Author(s):

Raul G. Nogueira ◽

Jason M. Davies ◽

Rishi Gupta ◽

Ameer E. Hassan ◽

Thomas Devlin ◽

...

Keyword(s):

Artificial Intelligence ◽

Acute Stroke ◽

Systems Of Care ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Number Of Patients ◽

The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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Incorporation of relative cerebral blood flow into CT perfusion maps reduces false ’at risk' penumbra

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013268 ◽

2017 ◽

Vol 10 (7) ◽

pp. 657-662 ◽

Cited By ~ 2

Author(s):

Shlomi Peretz ◽

David Orion ◽

David Last ◽

Yael Mardor ◽

Yotam Kimmel ◽

...

Keyword(s):

At Risk ◽

Acute Stroke ◽

Ct Perfusion ◽

False Negative ◽

Stroke Patients ◽

True Negative ◽

True Negative Rate ◽

Negative Rate ◽

Perfusion Maps

PurposeThe region defined as ‘at risk’ penumbra by current CT perfusion (CTP) maps is largely overestimated. We aimed to quantitate the portion of true ‘at risk’ tissue within CTP penumbra and to determine the parameter and threshold that would optimally distinguish it from false ‘at risk’ tissue, that is, benign oligaemia.MethodsAmong acute stroke patients evaluated by multimodal CT (NCCT/CTA/CTP) we identified those that had not undergone endovascular/thrombolytic treatment and had follow-up NCCT. Maps of absolute and relative CBF, CBV, MTT, TTP and Tmax as well as summary maps depicting infarcted and penumbral regions were generated using the Intellispace Portal (Philips Healthcare, Best, Netherlands). Follow-up CT was automatically co-registered to the CTP scan and the final infarct region was manually outlined. Perfusion parameters were systematically analysed – the parameter that resulted in the highest true-negative-rate (ie, proportion of benign oligaemia correctly identified) at a fixed, clinically relevant false-negative-rate (ie, proportion of ‘missed’ infarct) of 15%, was chosen as optimal. It was then re-applied to the CTP data to produce corrected perfusion maps.ResultsForty seven acute stroke patients met selection criteria. Average portion of infarcted tissue within CTP penumbra was 15%±2.2%. Relative CBF at a threshold of 0.65 yielded the highest average true-negative-rate (48%), enabling reduction of the false ‘at risk’ penumbral region by ~half.ConclusionsApplying a relative CBF threshold on relative MTT-based CTP maps can significantly reduce false ‘at risk’ penumbra. This step may help to avoid unnecessary endovascular interventions.

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Turnaround Time of Acute Multi-Modal Stroke Imaging Should Not Be More Than 11 Minutes

10.21203/rs.3.rs-57503/v1 ◽

2020 ◽

Author(s):

Channa Senanayake ◽

James Beharry ◽

Stanley Tsui ◽

Paul Mouthaan ◽

Teddy Y. Wu ◽

...

Keyword(s):

Acute Stroke ◽

Multimodal Imaging ◽

Ct Perfusion ◽

High Volume ◽

Turnaround Time ◽

Real World Data ◽

Stroke Imaging ◽

Ct Angiogram ◽

Contrast Ct ◽

Stroke Assessment

Abstract Background: Multimodal stroke imaging (Non-contrast CT, CT perfusion and CT angiogram) is essential to acute stroke assessment, there is currently no benchmark for this key process from real world data. Methods: Retrospective review of the turnaround time of consecutive multimodal imaging performed for acute stroke assessment at two high volume stroke centers in Australasia from July to September 2019.Results: 252 imaging studies were included from both sites. The overall median time from acquisition to imaging availability was 13 minutes (IQR 11- 16). The median for Christchurch and Box Hill were 11 minutes (IQR 10 – 12) and 15 minutes (IQR 13 – 19) respectively. Conclusions: Multimodal stroke imaging turnaround time of 11 minutes is a reasonable benchmark.

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Abstract WP42: CT Perfusion in Acute Stroke: Substantial Value Beyond Penumbra

Stroke ◽

10.1161/str.44.suppl_1.awp42 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Sarah W Meng ◽

Michael Hewitt ◽

Xiang Liu

Keyword(s):

Acute Stroke ◽

Ct Perfusion ◽

Infarct Volume ◽

Treatment Options ◽

Vascular Occlusion ◽

Diagnostic Sensitivity ◽

Detection Sensitivity ◽

Imaging Protocol ◽

Vascular Thrombosis ◽

Area Of Interest

Purpose: The role of CT Perfusion (CTP) in evaluation of acute stroke remains controversial, especially in determining ischemic penumbra and core infarct. Thus, our institution suspended CTP as part of the acute stroke imaging protocol, and now includes a non-contrast head CT (NCCT) and CT angiography (CTA) of the head and neck. We performed a retrospective review of cases using NCCT, CTA and CTP (CT-CTP) and cases using NCCT and CTA (CT-CTA protocol) at our institution from 2009 to 2011, to assess what, if any, substantial benefit CTP provides in the management of acute stroke. Methods: A total of 758 cases were reviewed, including 375 cases in the CT-CTP protocol and 383 cases in the CT-CTA protocol. Acute infarcts limited to the area covered by CTP were reviewed to compare the diagnostic sensitivity of the two protocols. Followup DWI or NCCT was used as the reference standard for final infarct size. Infarct volume was measured by freehand region of interest measurement. A subset group with final infarct volume > 30ml was also reviewed to explore the detection sensitivity of vascular thrombosis. Results: CTP deficits were reported in all 71 cases with a final infarct volume of 2.8 ml and above. Conversely, in the same category, 23 of 96 (24%) cases were reported as negative with CT-CTA protocol. Of the 10 cases with final infarct volume > 30ml and reported as negative in the CT- CTA protocol, 7of 10 had 2nd or 3rd order vascular thromboses, including 6 cases with infarct volume > 50ml. Only 2 of 45 thromboses were missed in the same category with CT-CTP protocol. Vascular thrombosis was missed in 1 of 10 cases with final infarct volume > 30ml in the CT-CTP protocol where NCCT was reported as negative but had positive CTP deficits. Conclusions: There is a substantially greater detection rate of 2nd and 3rd order vascular thrombosis when CTP is performed, including cases when NCCT is deemed negative. We speculate that a negative NCCT may provide false assurance, but that CTP deficits will guide attention to the area of interest, ultimately increasing detection of vascular occlusion and potentially influencing treatment options in the setting of acute stroke. Additionally, CTP significantly increases the diagnostic sensitivity of acute stroke compared to a combination of NCCT and CTA alone.

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Baseline ASPECTS and hypoperfusion intensity ratio influence the impact of first pass reperfusion on functional outcomes

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015953 ◽

2020 ◽

pp. neurintsurg-2020-015953 ◽

Cited By ~ 1

Author(s):

Mahmoud H Mohammaden ◽

Diogo C Haussen ◽

Leonardo Pisani ◽

Alhamza R Al-Bayati ◽

Catarina Perry da Camara ◽

...

Keyword(s):

Clinical Outcomes ◽

Intensity Ratio ◽

Functional Outcomes ◽

Ct Perfusion ◽

Functional Independence ◽

Performance Metric ◽

Imaging Characteristics ◽

First Pass ◽

Contrast Ct ◽

The Impact

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.MethodsA prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR <0.3 versus ≥0.3. Univariable and multivariable analyses were performed to establish the predictors of 90-day functional independence (modified Rankin Scale (mRS) ≤2) in each subgroup.ResultsA total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR <0.3 (62.9% vs 52.8%, adjusted OR 1.524; 95% CI 0.592 to 3.920, p=0.38).ConclusionsThe impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

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Abstract 40: The Impact of an Institutional Acute Stroke Protocol on Time to Treatment of Childhood Stroke

Stroke ◽

10.1161/str.45.suppl_1.40 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Melissa Shack ◽

Andrea Andrade ◽

Manohar Shroff ◽

Mahendranath Moharir ◽

Ivanna Yau ◽

...

Keyword(s):

Acute Stroke ◽

Symptom Onset ◽

False Negative ◽

Antithrombotic Agents ◽

Antithrombotic Treatment ◽

Time Intervals ◽

Delayed Treatment ◽

Pediatric Hospitals ◽

Time To Initiation ◽

The Impact

Introduction: In pediatric stroke, reported median delays from symptom onset to imaging diagnosis are 16-24hrs. This results in delayed treatment initiation. The impact of an Acute Stroke Protocol in pediatric hospitals has not been reported. Such a program was implemented at SickKids in 2005. The current study measured the impact of this protocol on delays to diagnosis and initiation of antithrombotic agents. Methods: We compared time to diagnosis and treatment in children (age 1mo-18yrs) with acute AIS diagnosed after stroke protocol implementation (‘post-protocol’ from 2005-2012), to 209 children diagnosed ‘pre-protocol’ 1992-2004. Focused health record reviews abstracted intervals from symptom onset to diagnosis and to initiation of first antithrombotic treatment. We statistically compared time intervals in pre and post-protocol cohorts. Results: Among 118 children diagnosed post-protocol (75 outpatient and 43 inpatient strokes), median age was 5.8 years with 65 males. Median delay from symptom onset to diagnosis in post-protocol children was similar to pre-protocol children, for all strokes (19.9hrs vs 22.7hrs respectively; p=0.24), outpatient (22.4hrs vs 29.1hrs; p=0.12) and inpatient strokes (12.8hrs vs 14.6hrs; p=0.92). The main contributors to diagnosis beyond 6 hrs were delays in initial neuroimaging (25% of delays) and false-negative neuroimaging results (19% of delays) in CT scan as first test. The interval from diagnosis to antithrombotic treatment was more frequently within 24 hours for children treated post-protocol (55.1% vs 18.7% pre-protocol;p<0.0001) and in post-protocol children this interval was median 4.5 hrs (IQR 1.9-16.6). Also children with inpatient strokes more frequently received antithrombotic agents post-protocol (58% vs 35% pre-protocol;p=0.031). The types of antithrombotic treatments were similar (p=0.337). Conclusions: The implementation of an Acute Stroke Protocol in our children’s hospital reduced the time to initiation of antithrombotic treatment. As thrombolysis and other hyper-acute treatments become available, the implementation of institutional Acute Stroke Protocols in children’s hospitals will be an important strategy to increase access to these therapies for children with AIS.

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Endovascular treatment beyond 24 hours from the onset of acute ischemic stroke: the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS)

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018045 ◽

2021 ◽

pp. neurintsurg-2021-018045

Author(s):

Ilaria Casetta ◽

Enrico Fainardi ◽

Giovanni Pracucci ◽

Valentina Saia ◽

Stefano Vallone ◽

...

Keyword(s):

Acute Stroke ◽

Ct Perfusion ◽

Case Fatality ◽

Functional Independence ◽

Primary Outcome Measure ◽

Stroke Patients ◽

Infarct Core ◽

Endovascular Thrombectomy ◽

Symptomatic Intracranial Hemorrhage ◽

Contrast Ct

BackgroundClinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset.MethodsWe analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH).ResultsSuccessful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0–2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%.ConclusionsThese findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.

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Radiation exposure of computed tomography imaging for the assessment of acute stroke

Neuroradiology ◽

10.1007/s00234-020-02548-z ◽

2020 ◽

Author(s):

Sebastian Zensen ◽

Nika Guberina ◽

Marcel Opitz ◽

Martin Köhrmann ◽

Cornelius Deuschl ◽

...

Keyword(s):

Computed Tomography ◽

Acute Stroke ◽

Radiation Exposure ◽

Ct Perfusion ◽

Dose Length Product ◽

Ct Dose ◽

Dose Monitoring ◽

Ct Protocol ◽

Ct Dose Index ◽

Contrast Ct

Abstract Purpose To assess suspected acute stroke, the computed tomography (CT) protocol contains a non-contrast CT (NCCT), a CT angiography (CTA), and a CT perfusion (CTP). Due to assumably high radiation doses of the complete protocol, the aim of this study is to examine radiation exposure and to establish diagnostic reference levels (DRLs). Methods In this retrospective study, dose data of 921 patients with initial CT imaging for suspected acute stroke and dose monitoring with a DICOM header–based tracking and monitoring software were analyzed. Between June 2017 and January 2020, 1655 CT scans were included, which were performed on three different modern multi-slice CT scanners, including 921 NCCT, 465 CTA, and 269 CTP scans. Radiation exposure was reported for CT dose index (CTDIvol) and dose-length product (DLP). DRLs were set at the 75th percentile of dose distribution. Results DRLs were assessed for each step (CTDIvol/DLP): NCCT 33.9 mGy/527.8 mGy cm and CTA 13.7 mGy/478.3 mGy cm. Radiation exposure of CTP was invariable and depended on CT device and its protocol settings with CTDIvol 124.9–258.2 mGy and DLP 1852.6–3044.3 mGy cm. Conclusion Performing complementary CT techniques such as CTA and CTP for the assessment of acute stroke increases total radiation exposure. Hence, the revised DRLs for the complete protocol are required, where our local DRLs may help as benchmarks.

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Abstract TP311: Multidisciplinary Stroke Simulation: Novel Team Based Approach to Decrease Door-to-Needle Times

Stroke ◽

10.1161/str.47.suppl_1.tp311 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Christopher A Mutch ◽

Zachary Threlkeld ◽

Sara Cole ◽

Christine Martin ◽

Benjamin Kozak ◽

...

Keyword(s):

Acute Stroke ◽

Ct Perfusion ◽

Stroke Care ◽

Simulated Patients ◽

Ct Scanner ◽

Acute Stroke Care ◽

Before And After ◽

Care Guidelines ◽

Multidisciplinary Simulation ◽

The Impact

Introduction: In acute stroke, time equals brain. Minimizing time to treatment maximizes eligibility and effectiveness of fibrinolytics. Timely treatment of acute stroke requires precise coordination of a multidisciplinary team ranging from first responders to neurointerventionalists. Simulation-based learning allows participants to hone their skills and make mistakes in a controlled environment. To our knowledge, the impact of multidisciplinary stroke simulation has not been reported in literature. Here we describe our initial experience implementing such a simulation. Hypothesis: Participation in stroke simulation will improve knowledge of acute stroke care guidelines and decrease door-to-needle time. Methods: Neurology, emergency medicine and radiology trainees, EMTs, nurses, medical students, technologists, and pharmacists took part in the evaluation and treatment of simulated patients with stroke symptoms in actual clinical settings from ambulance to ED to CT scanner to IR suite. Neurology and neuroradiology faculty debriefed participants following simulations. Questions on stroke care (derived from the 2013 AHA/ASA guideline and 2015 update) were sent to likely participants before and after the simulation; those who completed pre/post quizzes and the simulation were included in analysis. Results: Survey response rate was 86%. All participants had improved scores on the post-simulation quiz, scoring an average of 19% higher, 95% CI [8%, 29%]. For example, correct responses that IV tPA is not contraindicated prior to endovascular therapy improved from 64 to 100% after the simulation; responses correctly identifying the appearance of ischemic penumbra on CT perfusion imaging increased from 27 to 73%. Nearly all (92%) respondents would recommend the simulation to their peers. Conclusions: Simulation of acute stroke scenarios improves participants’ knowledge of acute stroke management guidelines and may improve door-to-needle time. We present a novel framework for multidisciplinary simulation, which could be implemented at other institutions. Further evaluation of simulation effect on door-to-needle time is ongoing.

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