Rapid Treatment of Acute Ischemic Stroke Using a Computed Tomography-Based Reperfusion Protocol: The Reality of a Local Community Hospital with Limited Resources

OBJECTIVE: In patients with acute ischemic stroke (AIS), prognosis strongly depends on the onset-to-recanalization time. The Ishinomaki protocol for rapid recanalization has been used since October 2017. This protocol determines the indication for reperfusion therapy based on computed tomography (CT)/three-dimensional CT angiography (3DCTA) findings and intends to reduce the onset-to-recanalization time. We aimed to compare the outcomes before and after protocol introduction. METHODS: Our hospital is the only thrombectomy-capable center in Ishinomaki, Tome, and Kesennuma medical area. Before protocol introduction (April 2014–June 2016), both CT and magnetic resonance imaging were performed to determine the indications for intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) or mechanical thrombectomy within 6 hours of disease onset. However, after protocol introduction (from October 2017), plain CT and 3DCTA were used. We collected data on patients who underwent mechanical thrombectomy and/or IV rt-PA before (n = 13) and after (n = 34) the protocol introduction. The required time from onset to door (OTD), door to needle (DTN), needle to puncture (NTP), puncture to recanalization (PTR), and door to recanalization (DTR) were compared before and after protocol introduction. Furthermore, thrombolysis in cerebral infarction (TICI) grades and modified Rankin scale (mRS) scores at discharge were compared. RESULTS: The outcomes before and after protocol introduction were as follows: OTD: 105 ± 73.8 (mean ± standard deviation) vs. 120 ± 68.1 min (p = 0.376, Mann–Whitney U test); DTN: 62.9 ± 15.9 vs. 41 ± 17 min (p <0.01); NTP: 112 ± 69.8 vs. 39.9 ± 33.7 min (p <0.01); PTR: 87.9 ± 45.4 vs. 52.5 ± 27.9 min (p <0.01); and DTR, 230 ± 69.9 vs. 110 ± 40.3 min (p <0.0001). Before and after protocol introduction, the proportion of patients with TICI grade 2b–3, mRS score of 0–2 at discharge, and mRS score of 5–6 were 54% vs. 50% (p = 0.815, Fisher’s exact test), 23% vs. 21% (p = 0.854), and 15% vs. 50% (p = 0.046), respectively. CONCLUSION: The Ishinomaki protocol reduced the mean DTR time by 120 min. The reduction in treatment time was due to the change in CT-based recanalization and collaboration with emergency physicians and paramedics. There was no increase in good outcomes, but there was a significant increase in poor outcomes at discharge. Patients who could not be salvaged were indicated for reperfusion therapy as CT and 3DCTA cannot detect the ischemic core.