Streamlined Poststroke Treatment Order Sets During the SARS-CoV-2 Pandemic

Background and Purpose: Standard poststroke treatment monitoring protocols are made problematic during the coronavirus disease 2019 (COVID-19) pandemic by the frequency of patient assessments, requiring repeated donning and doffing procedures in a short interval of time. Methods: A streamlined poststroke treatment protocol was developed to limit frequency of patient encounters while maximizing the yield of each encounter by grouping together different components of poststroke care into single bedside visits. Results: Streamlined order sets were developed late March 2020. During the first 6 weeks following implementation, 70 patients were admitted to a geographically defined designated warm COVID-19 unit with modified poststroke care order sets. Of these, 33 (47.1%) patients received acute reperfusion therapy. All but 3 patients evolved favorably with either stable or improving National Institutes of Health Stroke Scale at 24 hours. In the 3 patients who experienced early neurological deterioration, none were found to be attributable to insufficient patient monitoring. Conclusions: Adapting preexisting poststroke care protocols may be necessary while the risk of COVID-19 infection remains high. We propose a streamlined approach to facilitate poststroke monitoring in patients with stroke with unknown COVID status.

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Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

Cerebrovascular Diseases ◽

10.1159/000513396 ◽

2021 ◽

pp. 1-8

Author(s):

Ki-Woong Nam ◽

Chi Kyung Kim ◽

Sungwook Yu ◽

Jong-Won Chung ◽

Oh Young Bang ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Risk ◽

Multivariable Analysis ◽

National Institutes Of Health ◽

Risk Scores ◽

Stroke Patients ◽

Nihss Score ◽

Early Neurological Deterioration ◽

Close Relationship ◽

The Relationship

Background: Stroke risk scores (CHADS2 and CHA2DS2-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. Objective: The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. Methods: We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS2 and CHA2DS2-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. Results: A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA2DS2-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA2DS2-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA2DS2-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS2 scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. Conclusions: High CHA2DS2-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

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Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes

Stroke ◽

10.1161/strokeaha.118.023789 ◽

2019 ◽

Vol 50 (4) ◽

pp. 1007-1009 ◽

Cited By ~ 10

Author(s):

Anne Berberich ◽

Christine Schneider ◽

Tilman Reiff ◽

Christoph Gumbinger ◽

Peter Arthur Ringleb

Keyword(s):

Functional Outcome ◽

Antiplatelet Therapy ◽

Scale Score ◽

Dual Antiplatelet Therapy ◽

Treatment Strategies ◽

National Institutes Of Health ◽

Bleeding Complications ◽

Positive Effects ◽

End Point ◽

Early Neurological Deterioration

Background and Purpose— In 20% to 30% of patients with lacunar strokes, early neurological deterioration (END) occurs within the first days after stroke onset. However, effective treatment strategies are still missing for these patients. The purpose of this study was to analyze efficacy of dual antiplatelet therapy (DAPT) in patients presenting with END. Methods— Four hundred fifty-eight patients with lacunar strokes and corresponding neuroimaging evidence of lacunar ischemia were retrospectively screened for END, which was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale points, ≥2 National Institutes of Health Stroke Scale points for limb paresis, or documented clinical deterioration within 5 days after admission. Patients with END were treated with DAPT according to in-house standards. Primary efficacy end point was fulfilled if National Institutes of Health Stroke Scale score at discharge improved at least to the score at admission. Secondary end points were Rankin Scale score, further clinical fluctuation, and symptomatic bleeding complications. Results— END occurred in 130 (28%) of 458 patients with lacunar strokes. Ninety-seven (75%) of these patients were treated with DAPT after END, mostly for 5 days. DAPT was associated with improved functional outcome. The primary end point was met in 68% (66) of patients with DAPT compared with 36% (12) of patients with standard treatment ( P =0.0019). Further clinical fluctuations were absent in 79% (77) of patients with DAPT versus 33% (11) of patients without DAPT ( P <0.001). Symptomatic bleeding complications were not observed in any patient. Conclusions— The results demonstrated potential positive effects of DAPT in patients with progressive lacunar strokes.

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Neutrophil-to-Lymphocyte Ratio Predicts Cerebral Edema and Clinical Worsening Early After Reperfusion Therapy in Stroke

Stroke ◽

10.1161/strokeaha.120.032130 ◽

2021 ◽

Author(s):

Daniela Ferro ◽

Margarida Matias ◽

Joana Neto ◽

Rafael Dias ◽

Goreti Moreira ◽

...

Keyword(s):

Ischemic Stroke ◽

Systemic Inflammatory Response Syndrome ◽

Inflammatory Response ◽

Systemic Inflammation ◽

Cerebral Edema ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Reperfusion Therapy ◽

Systemic Inflammatory Response ◽

Early Neurological Deterioration

Background and Purpose: The mechanisms linking systemic inflammation to poor outcome in ischemic stroke are not fully understood. The authors investigated if peripheral inflammation following reperfusion therapy leads to an increase in cerebral edema (CED), thus hindering the clinical recovery. Methods: We designed a single-center study conducted at Centro Hospitalar Universitário São João between 2017 and 2019. Inclusion criteria were being adult, having an anterior circulation acute ischemic stroke, and receiving reperfusion therapy. Neutrophil-to-lymphocyte, platelet-to-lymphocyte ratios, and the systemic inflammatory response syndrome criteria were determined. The presence and grade of CED were evaluated on the computed tomography performed 24 hours following event. The clinical outcomes included early neurological deterioration and functional dependence at 90 days. Adjusted odds ratio and 95% CI were obtained by ordinal and logistic regression models. Optimal cutoff values were defined using receiver operating characteristic analysis in the training cohort and validated in an independent data set. Results: Five hundred fifty-three patients were included. Neutrophil-to-lymphocyte increased with higher degrees of CED at 24 hours (adjusted odds ratio, 1.34 [1.09–1.68], P <0.01) and was associated with early neurological deterioration (adjusted odds ratio, 1.30 [1.04–1.63], P <0.05) and poor functional status at 90 days (adjusted odds ratio, 1.79 [1.28–2.48], P <0.01). Platelet-to-lymphocyte was not associated with the outcomes. Systemic inflammatory response syndrome was related to CED due to altered white blood cell counts. Neutrophil-to-lymphocyte was the best predictor with an area under the curve around 0.7. Neutrophil-to-lymphocyte ≥7 had and accuracy, sensitivity, and specificity around 60%. Conclusions: Increased systemic inflammation is linked to the severity of CED early after reperfusion therapy in stroke. Easily obtained inflammatory markers convey early warning alerts for patients at risk of severe neurological complications with an impact on long-term functional outcome. CED quantification should be included as an end point in proof-of-concept trials in immunomodulation in stroke.

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Prediction of Infarct Growth and Neurological Deterioration in Patients with Vertebrobasilar Artery Occlusions

Journal of Clinical Medicine ◽

10.3390/jcm9113759 ◽

2020 ◽

Vol 9 (11) ◽

pp. 3759

Author(s):

Seungyon Koh ◽

Ji Hyun Park ◽

Bumhee Park ◽

Mun Hee Choi ◽

Sung Eun Lee ◽

...

Keyword(s):

Mental Status ◽

Reperfusion Therapy ◽

Posterior Circulation ◽

National Institutes Of Health ◽

Neurological Deterioration ◽

University Hospital ◽

Vertebrobasilar Artery ◽

Hospital Registry ◽

Incomplete Occlusion

We aimed to identify predictors of infarct growth and neurological deterioration (ND) in vertebrobasilar occlusions (VBOs) with a focus on clinical-core mismatch. From 2010 to 2018, VBO patients were selected from a university hospital registry. In total, 138 VBO patients were included. In these patients, a posterior circulation Alberta Stroke Program Early CT score (PC-ASPECTS) less than 6 was associated with futile outcome. Within patients with feasible cores, a decrease in PC-ASPECTS score of 2 or more on follow-up imaging was classified as infarct growth and could be predicted by a National Institutes of Health Stroke Scale (NIHSS) mental status subset of 1 or higher (odds ratio (OR): 3.34, 95% confidence interval (CI) (1.19–9.38), p = 0.022). Among the 73 patients who did not undergo reperfusion therapy, 13 patients experienced ND (increase in discharge NIHSS score of 4 or more compared to the initial presentation). Incomplete occlusion (vs. complete occlusion, OR 6.17, 95% CI (1.11–34.25), p = 0.037), poorer collateral status (BATMAN score, OR: 1.91, 95% CI (1.17–3.48), p = 0.009), and larger infarct cores (PC-ASPECTS, OR: 1.96, 95% CI (1.11–3.48), p = 0.021) were predictive of ND. In patients with VBO, an initial PC-ASPECTS of 6 or more, but with a decrease in the mental status subset of 1 or more can predict infarct growth, and may be used as a criterion for clinical-core mismatch. ND in VBO patients presenting with milder symptoms can be predicted by incomplete occlusion, poor collaterals, and larger infarct cores.

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Abstract WP251: Sleep Apnea and Early Neurological Deterioration in Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp251 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Cindy W Yoon ◽

Joung-Ho Rha ◽

Hee-Kwon Park

Keyword(s):

Ischemic Stroke ◽

Sleep Apnea ◽

Acute Ischemic Stroke ◽

Acute Phase ◽

National Institutes Of Health ◽

Neurological Deterioration ◽

Apnea Hypopnea Index ◽

Early Neurological Deterioration ◽

Multivariable Regression ◽

The Impact

Background and Purpose: Evidence of an association between sleep apnea (SA) and early neurological deterioration (END) in acute phase ischemic stroke is scant. We investigated the prevalence of SA and the impact of SA severity on END in acute ischemic stroke (AIS) patients. Methods: We prospectively enrolled consecutive AIS patients admitted to our stroke unit within 72 hours of symptom onset. SA severity was assessed with ApneaLink - a validated portable respiratory monitor. SA was defined as an apnea-hypopnea index (AHI) of ≥ 5/hour. END was defined as an incremental increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥ 1 point in motor power, or ≥ 2 points in the total score within the first week after admission. Results: Of the 305 patients studied, 254 (83.3%) patients had SA (AHI ≥ 5/hour), and of these, 114 (37.4%) had mild SA (AHI 5-14/hour), 59 (19.3%) had moderate SA (AHI 15-29/hour), and 81 (26.6%) had severe SA (AHI ≥ 30/hour). Thirty-six (11.8%) patients experienced END: 2 of the 51 (3.9%) patients without SA and 34 of the 254 (14.4%) patients with SA. Multivariable regression analysis showed AHI independently predicted END (odds ratio 1.024; 95% confidence interval 1.006 to 1.042; p = 0.008). Conclusions: SA is common in the acute phase of ischemic stroke, and SA severity is associated with the risk of END.

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Abstract WP380: Simulation Based Acute Stroke Responders Training Improves Door-to-Thrombolytic Time

Stroke ◽

10.1161/str.48.suppl_1.wp380 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Karen Tse-Chang ◽

Ann Mendoza ◽

Jeff MacKenzie ◽

Katrina Woolfolk ◽

Kimberly Jones ◽

...

Keyword(s):

Adult Learners ◽

Leadership Skills ◽

National Institutes Of Health ◽

Training Data ◽

Honor Roll ◽

Simulation Based ◽

Order Sets ◽

Tissue Plasminogen ◽

Before And After ◽

Radiology Technicians

Background: The evaluation of acute ischemic stroke (AIS) patients should be performed expeditiously. Our stroke program maintained our Target: Stroke Honor Roll status in 2014, however, door-to-needle (DTN) time in Quarter 1 and 2 of 2015 showed no significant improvement and did not achieve DTN under 60 minutes in 75% of patients nor under 45 minutes in 50% of patients, despite in-servicing Emergency Department (ED)’s staff on program goals and order sets. The purpose of this project was to more effectively educate emergency stroke responders on clinical recognition and implementation of the organization’s stroke protocol order sets. Simulation as an experiential learning technique, promoting, applied thinking, delegation, and leadership skills. Evidence suggests simulation based training for adult learners promote their engagement and immediate application of learned material. Methods: Simulation: Stroke code responders, including 5 nurses per session, participated in the 90 minute scenario. Stroke protocol order sets were reviewed prior to the simulation of a right hemispheric syndrome. Participants elicited a focused history, National Institutes of Health Stroke Scale, relayed the findings to the neurologist, evaluate exclusion and inclusion criteria, and administered weight-based doses of tissue plasminogen activator (tPA). After a debrief, the participants repeated the simulation to reinforce new knowledge and skills. Descriptive statistics were used to compare mean DTN time before and after simulation training. Results: 153 ED nurses, 8 ED physicians, 6 neurologists, 4 pharmacists, 6 radiology technicians, and 10 phlebotomists participated. Pre -training Q1-Q2 2015 median DTN was 55 minutes, 65% </= 60 minutes, and 31% </= 45 minutes. Post-training data from Q1 2016 median DTN was 46 minutes, 75% </= 60 minutes, and 50% </= 45 minutes. Conclusion: Simulation based stroke responders training helped to decrease DTN time.

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Abstract P843: Stroke Patient Monitoring Used in Adult Emergency Department During Covid-19 Acting Both Rapidly and Safely

Stroke ◽

10.1161/str.52.suppl_1.p843 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Alsacia Pasci-Sepulveda ◽

Crismely Perdomo ◽

Kyra Lizardo ◽

Joshua Z Willey

Keyword(s):

Emergency Department ◽

New York ◽

Patient Monitoring ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

World Health ◽

Level Of Care ◽

Multidisciplinary Teams ◽

Improvement Project ◽

Monitoring Protocols

Introduction: The healthcare system was facing two challenges: acute patients presenting to the adult emergency department diagnosed with Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)/ COVID-19 and how to treat life-threating emergencies. Emergency, neurovascular and multidisciplinary teams, therefore, had to be ready to treat these emergencies rapidly and safely. The goals were to balance substantial needs and preserve resources during this extraordinary time for incoming acutely ill patients. Background: The World Health Organization (WHO) defined COVID-19 as a pandemic. New York City was the epicenter for the 2019-2020 COVID -19 pandemic. There were 30,000 confirmed cases resulting in over 2,500 hospitalizations as of March 30, 2020. Hence, it was vital to develop new monitoring protocols, based upon the expert opinion of the stroke and multidisciplinary leadership at New York Presbyterian Hospital that required minimum monitoring and criteria for admission necessary to safely care for complex stroke patients. Purpose: This quality improvement project evaluated patient outcomes after the implementation of the modified stroke protocol. Methods: Retrospective data review was conducted for patients who presented via the Emergency Department with stroke symptoms, and were treated with intravenous thrombolysis (IVT) between 3/30 and 6/30/2020, with a focus on whether patients required a higher level of care or developed hemorrhagic transformation post IVT. Results: The sample consisted of 10 patients (60% female), median age 54 (range 37-73). Length of stay ranged from 2 to 12 days. Two patients (20%) were SARS-CoV-2 positive. None (0%) of the patients developed hemorrhagic transformation. None (0%) of the patients admitted to non-ICU units required critical care transfer or interventions within 24 hours of receiving IVT. Six (60%) patients were discharged to home. Conclusions: Using the modified patient monitoring protocol post IVT none of the patients developed symptomatic hemorrhagic transformation and did not require transfer to higher level of care within 24 hours. If there is another wave of the COVID-19 pandemic, this protocol could be adopted and its effectiveness and safety can continue to be evaluated.

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Abstract P85: Impact of Covid-19 Pandemic on Hospitalizations and Outcomes of Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (pcnasp)

Stroke ◽

10.1161/str.52.suppl_1.p85 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Xin Tong ◽

Sallyann Coleman King ◽

Erika Odom ◽

Quanhe Yang

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

The United States ◽

Emergency Department Visits ◽

National Institutes Of Health ◽

Hospital Death ◽

Stroke Patients ◽

Stroke Treatment

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged <65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p<0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p<0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p<0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p<0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods. Conclusion: A higher percentage of younger (<65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.

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Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011690 ◽

2015 ◽

Vol 8 (5) ◽

pp. 461-465 ◽

Cited By ~ 16

Author(s):

Joon-Tae Kim ◽

Suk-Hee Heo ◽

Woong Yoon ◽

Kang-Ho Choi ◽

Man-Seok Park ◽

...

Keyword(s):

Ischemic Stroke ◽

Multivariate Logistic Regression Analysis ◽

National Institutes Of Health ◽

Neurological Deterioration ◽

Favorable Outcome ◽

Minor Stroke ◽

Multivariate Logistic Regression ◽

Full Data ◽

Minor Ischemic Stroke ◽

Early Neurological Deterioration

BackgroundPatients presenting with minor ischemic stroke frequently have early neurological deterioration (END) and poor final outcome. The optimal management of patients with END has not been determined.ObjectiveTo investigate rescue IA therapy (IAT) when patients with acute minor ischemic stroke develop END.MethodsThis was a retrospective study of consecutively registered patients with acute minor stroke and END. ‘END’ was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) scores by 1 or more points (or development of new neurological symptoms) and ‘ΔEND−NIHSS’ was defined as numerical difference between NIHSS scores at the time of END and before END. Rescue IAT following END was adjusted for the covariates to evaluate the association between IAT and favorable outcome at 3 months.ResultsAmong 982 patients with acute minor ischemic stroke, END occurred in 232 (23.6%). Of the 209 patients with END with full data available, 87 (41.6%) had favorable outcomes at 3 months. Rescue IAT following END was performed in 28 (13.4%). Favorable 3-month outcomes were seen in 50% of patients undergoing rescue IAT, including 8/19 (42.1%) undergoing rescue IAT beyond 8 h. By multivariate logistic regression analysis, rescue IAT following END was independently associated with favorable outcome at 3 months (OR=10.9; 95% CI 3.06 to 38.84; p<0.001).ConclusionsThe results suggest that rescue IAT may be safe and effective when END occurs in selected patients with acute minor ischemic stroke. Further prospective and randomized studies are needed to confirm our results.

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Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Stroke ◽

10.1161/str.52.suppl_1.p32 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Noah Grose ◽

Cassandra Forrest ◽

Sharon Heaton ◽

Vivien Lee

Keyword(s):

Acute Stroke ◽

Nurse Practitioners ◽

Final Diagnosis ◽

Reperfusion Therapy ◽

National Institutes Of Health ◽

Advanced Practice ◽

Intravenous Tissue Plasminogen Activator ◽

The Hours ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at <0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

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