Effect of early neuroendovascular team involvement in acute stroke protocol: a retrospective study

Abstract

Introduction: Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality, with outcomes dependent on timely treatment. Tissue plasminogen activator (tPA) and endovascular therapy (EVT) improve outcomes, but delays reduce their efficacy. This study introduced a protocol featuring early participation of neuroendovascular interventionists and evaluated its association with treatment times and outcomes compared with conventional management.

Methods: This single-center retrospective study included patients with AIS transported to emergency room (ER) who received tPA or EVT between January 2010 and December 2022. Under the protocol, the stroke team-including neuroendovascular interventionists, who made the final decision on tPA and EVT-was activated by the emergency physician when stroke was suspected based on pre-hospital information. The stroke team was not activated if neuroendovascular interventionists were engaged in other procedures or if the ER physician suspected a non-stroke diagnosis. Upon arrival, the team commenced care, with neuroendovascular interventionists reviewing imaging and determining treatment strategies. Patients were categorized into protocol and conventional groups based on management under the new protocol or standard care. The primary outcome was a favorable neurological outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at discharge. Secondary outcomes included time metrics for initiation of tPA and/or EVT. Logistic regression analysis estimated the effects of the protocol, adjusting for confounders, including age, sex, baseline National Institutes of Health Stroke Scale score, and pre-hospital factors. Secondary outcomes were assessed using multiple linear regression.

Results: This study analyzed 501 patients, with 313 in the protocol group and 188 in the conventional group. Favorable neurological outcomes at discharge (mRS 0-2) were more frequent in the protocol group (44.4% vs. 31.9%; adjusted odds ratio: 2.92, 95% confidence interval [CI]: 1.83-4.66). The protocol group also showed shorter door-to-imaging time (-8.3 min), door-to-needle time (-55.9 min), door-to-puncture time (-59.8 min), and door-to-recanalization time (-73.7 min).

Conclusion: Early engagement of neuroendovascular specialists in the emergency pathway was associated with faster treatment initiation and a higher likelihood of favorable functional status at discharge in this retrospective cohort. Because residual confounding and temporal changes in stroke care cannot be excluded, prospective validation in other settings is warranted.

Keywords: door-to-treatment time; endovascular therapy; neurological outcomes; stroke team protocol; tissue plasminogen activator; workflow optimization.

Figure 1

Comparison of conventional and stroke team workflow for AIS. This figure compares workflows for AIS treatment under conventional and stroke team protocols. In the conventional workflow, the emergency room (ER) physicians manage initial care and imaging before summoning an interventional neuroradiologist for EVT. The stroke team protocol positions the neuroradiologist in the ER from the outset, enabling immediate initiation of tPA administration and EVT after imaging. CT, computed tomography; AIS, acute ischemic stroke; tPA, tissue plasminogen activator; EVT, endovascular therapy.

Figure 2

Flowchart of patient selection, summarizing exclusions and final cohort size. AIS, acute ischemic stroke; tPA, tissue plasminogen activator; NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale.

Figure 3

Adjusted neurological outcome. This figure shows the proportions of favorable neurological outcomes at discharge for the stroke team protocol and conventional workflows. The stroke team group had a higher proportion of favorable outcomes (44.4% vs. 31.9%), with an adjusted odds ratio of 2.92 (95% confidence interval: 1.83–4.66, p < 0.001). A favorable neurological outcome was defined as a modified Rankin Scale (mRS) score of 0–2.

Figure 4

Adjusted time-based outcomes. The stroke team protocol reduced treatment times, as indicated by the adjusted regression coefficients: door-to-imaging time (−8.3 min, 95% confidence interval [CI]: −10.5−−6.1, p < 0.001), door-to-needle time (−55.9 min, 95% CI: −62.7−−49.1, p < 0.001), door-to-puncture time (−59.8 min, 95% CI: −77.2−−42.5, p < 0.001), and door-to-recanalization time (−73.7 min, 95% CI: −97.1−−50.4, p < 0.001).