Thrombolysis in a stroke patient on dabigatran anticoagulation: case report and synopsis of published cases

We present the case of an aphasic 77-year-old stroke patient with left distal M1 occlusion who received rt-PA for thrombolysis while on oral anticoagulant treatment with dabigatran (150 mg b.i.d.). Coagulation parameters were normal (thrombin time 20 s, aPTT 20 s, INR 1.08) and the patient improved from an NIHSS of 15 to 5 within 24 h with sonographic evidence of M1 recanalization. She did not develop intracranial bleeding complications but showed unusually large diffuse skin ecchymoses. In our report, we give an overview of all reported cases of thrombolysis under dabigatran anticoagulation and discuss the questions of medication adherence under novel oral anticoagulants (NOA) and the safety of NOA in terms of secondary intracerebral hemorrhage after stroke

Implementation of stroke teams and simulation training shortened process times in a regional stroke network-A network-wide prospective trial.

To meet the requirements imposed by the time-dependency of acute stroke therapies, it is necessary 1) to initiate structural and cultural changes in the breadth of stroke-ready hospitals and 2) to find new ways to train the personnel treating patients with acute stroke. We aimed to implement and validate a composite intervention of a stroke team algorithm and simulation-based stroke team training as an effective quality initiative in our regional interdisciplinary neurovascular network consisting of 7 stroke units.We recorded door-to-needle times of all consecutive stroke patients receiving thrombolysis at seven stroke units for 3 months before and after a 2 month intervention which included setting up a team-based stroke workflow at each stroke unit, a train-the-trainer seminar for stroke team simulation training and a stroke team simulation training session at each hospital as well as a recommendation to take up regular stroke team trainings.The intervention reduced the network-wide median door-to-needle time by 12 minutes from 43,0 (IQR 29,8-60,0, n = 122) to 31,0 (IQR 24,0-42,0, n = 112) minutes (p < 0.001) and substantially increased the share of patients receiving thrombolysis within 30 minutes of hospital arrival from 41.5% to 59.6% (p < 0.001). Stroke team training participants stated a significant increase in knowledge on the topic of acute stroke care and in the perception of patient safety. The overall course concept was regarded as highly useful by most participants from different professional backgrounds.The composite intervention of a binding team-based algorithm and stroke team simulation training showed to be well-transferable in our regional stroke network. We provide suggestions and materials for similar campaigns in other stroke networks

Implementation of stroke teams and simulation training shortened process times in a regional stroke network-A network-wide prospective trial.

To meet the requirements imposed by the time-dependency of acute stroke therapies, it is necessary 1) to initiate structural and cultural changes in the breadth of stroke-ready hospitals and 2) to find new ways to train the personnel treating patients with acute stroke. We aimed to implement and validate a composite intervention of a stroke team algorithm and simulation-based stroke team training as an effective quality initiative in our regional interdisciplinary neurovascular network consisting of 7 stroke units.We recorded door-to-needle times of all consecutive stroke patients receiving thrombolysis at seven stroke units for 3 months before and after a 2 month intervention which included setting up a team-based stroke workflow at each stroke unit, a train-the-trainer seminar for stroke team simulation training and a stroke team simulation training session at each hospital as well as a recommendation to take up regular stroke team trainings.The intervention reduced the network-wide median door-to-needle time by 12 minutes from 43,0 (IQR 29,8-60,0, n = 122) to 31,0 (IQR 24,0-42,0, n = 112) minutes (p < 0.001) and substantially increased the share of patients receiving thrombolysis within 30 minutes of hospital arrival from 41.5% to 59.6% (p < 0.001). Stroke team training participants stated a significant increase in knowledge on the topic of acute stroke care and in the perception of patient safety. The overall course concept was regarded as highly useful by most participants from different professional backgrounds.The composite intervention of a binding team-based algorithm and stroke team simulation training showed to be well-transferable in our regional stroke network. We provide suggestions and materials for similar campaigns in other stroke networks

Exemplary team-based acute stroke care algorithm.

<p>The algorithm needs to be adapted to the infrastructure and staff availiability of each individual hospital. The algorithm relies on a seamless cooperation with preclinical emergency medical services and encourages working in parallel with defined tasks for each stroke team member. The stroke alert is a speed dial collective call that summons all team members simultaneously to their respective workplaces.</p

Study design and timeline of the INVN stroke team Rhein-Main quality campaign.

<p>Study design and timeline of the INVN stroke team Rhein-Main quality campaign.</p

Exemplary team-based acute stroke care algorithm.

<p>The algorithm needs to be adapted to the infrastructure and staff availiability of each individual hospital. The algorithm relies on a seamless cooperation with preclinical emergency medical services and encourages working in parallel with defined tasks for each stroke team member. The stroke alert is a speed dial collective call that summons all team members simultaneously to their respective workplaces.</p

Effect of the simulation training on perceived stroke-readiness and patient safety.

<p>Responses to a questionnaire distributed to n = 152 participants of 6 stroke units (University Hospital Frankfurt did not participate actively in the intervention phase) directly before and after the simulation-based 2.5 h stroke team training. Participants were asked to respond anonymously on a 5-point scale. Statistical significance was assessed with a Wilcoxon signed-rank test. A) *** p < 0.001 and B) *** p < 0.001.</p

Effects of the stroke team intervention on network-wide door-to-needle times.

<p>(A) Door-to-needle times of seven stroke units of the neurovascular network before and after the composite stroke team intervention. Data are given as median, 25 to 75% interquartile range (box) and extremes (whiskers). Statistical significance was assessed with a Mann-Whitney-U test, *** p < 0.001. (B) Individual median door-to-needle times in minutes of the seven stroke units before and after the stroke team intervention. Empty circles: University Hospital Frankfurt.</p

Rating of the interdisciplinary simulation training by the participants.

<p>Responses to a questionnaire distributed to n = 152 participants of 6 stroke units (University Hospital Frankfurt did not participate actively in the intervention phase) directly before and after the simulation-based 2.5 h stroke team training. Participants were asked to respond anonymously.</p