Oct 24, 2023

How We Shorten Door-To-Puncture Time and Achieve Top Stroke Outcomes

Last spring, a woman found her 65 year-old husband collapsed in their bedroom at around 7:00 in the morning, unable to speak. She called 911; EMS noted signs of a stroke and recorded a score of 4 on the Los Angeles Motor Scale, indicating a likely large vessel occlusion (LVO). The patient was rushed to the Eastside Neuroscience Institute, where our team started a mechanical thrombectomy within 75 minutes of his arrival.

Just 10 years ago, a patient like this would have likely been permanently disabled. This patient went home in just two days, with no lasting stroke effects. The story of his success illustrates how we have built an elite stroke center, with an approach that enables some of our region’s best outcomes.

“As a Thrombectomy-Capable Stroke Center certified by the Joint Commission, we’re well-equipped to handle a patient like this, and we’ve used a collaborative approach to ensure we’re constantly shortening our door-to-puncture times and delivering outstanding care,” says Steven O’Donnell, MD.

Our team was ready and waiting when this patient was routed to our location at Overlake Medical Center & Clinics. He immediately underwent a CT scan and had an NIH Stroke Scale score of 27, indicating a severe stroke with disabling deficits, including the inability to speak. The imaging revealed a large clot that started at the end of the of the left internal carotid artery (ICA) and extended slightly into the middle cerebral artery.

Since the patient’s wife hadn’t seen him in a healthy state since around 11:00 the night before, too much time had elapsed to safely administer intravenous tPA.

“The only thing that could have prevented him from having a massive stroke was mechanical thrombectomy,” Dr. O’Donnell says. “The good news is, we now have the tools to treat strokes like this in the acute period and reverse their effects – so long as we do it quickly.”

Our team performs 50-100 thrombectomies per year and our internal goal is to keep door-to-puncture times under 90 minutes. For this patient, puncture occurred at approximately 75 minutes and Dustin Hayward, MD, used a catheter to deploy suction and a stent retriever to completely remove the clot. One way we keep our times short is by using cutting-edge technology, including an AI imaging software that helps identify LVOs.

“Everyone in our Stroke Center has an app on their phones that alerts them when the software identifies an LVO – the system works so quickly that we sometimes get the alert before the emergency physician has called us and before our radiologist has seen the scans. It’s an example of how we’re doing everything we can to keep pushing ourselves to give these patients the best care, as fast as possible,” Dr. O’Donnell says.

While time is critical, so is expertise. In clinical trials, the success rate of removing clots via mechanical thrombectomy was between 75% and 80%. Our team is able to remove more than 80% of clots and we recently received the Gold Plus Quality Award for stroke care – the highest level of stroke recognition given by the American Heart Association.

The patient went home a little more than two days later. At his two-week follow-up appointment, he reported mild fatigue but was otherwise back to work and back to normal.

“The clot was very close to a critical part of the brain – if it wasn’t removed, this patient probably would have been permanently unable to talk and paralyzed on his right side,” Dr. O’Donnell says. “Fortunately, we were able to give this patient one of the best outcomes you can hope for. It’s a testament to how everyone in the chain of care – from EMS to the nurses, emergency medicine physician, radiologist, neurologist and neurosurgeon – put the patient first and worked seamlessly to do everything they could for him.”

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