Accepted Manuscript

Title: Imaging department organization in a stroke center and

workflow processes in acute stroke

Authors: Zarina Abdul Assis, Bijoy K. Menon, Mayank Goyal

PII: S0720-048X(17)30260-7
DOI: http://dx.doi.org/doi:10.1016/j.ejrad.2017.06.014
Reference: EURR 7874

To appear in: European Journal of Radiology

Received date: 4-5-2017

Accepted date: 18-6-2017

Please cite this article as: {http://dx.doi.org/

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Imaging department organization in a stroke center and workflow processes in acute stroke

Cover title: Imaging department organization in stroke care centers

Author names and affiliations:

1. Zarina Abdul Assis, DNB, DM, Department of Diagnostic imaging, Foothills medical Centre, University of

Calgary, Alberta, Canada T2N2T9

2. Bijoy K. Menon, MD, MSc, Calgary Stroke Program and the Department of Radiology, Clinical

Neurosciences and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada

3. Mayank Goyal ,MD, Department of Radiology, Seaman Family MR Research Centre

3330 Hospital Drive NW Calgary, AB T2E 4N1

Corresponding author: Mayank Goyal, MD.

Department of Radiology, Seaman Family MR Research Centre

Foothills Medical Centre, Calgary, AB T2E 4N1

mgoyal@ucalgary.ca

Abstract:

The imaging department is an integral part of the stroke management task force and plays a critical role. Accurate

and timely interpretation of images obtained in the emergency department and involvement in decision-making

has contributed immensely in stroke care. In fact, the treatment paradigm has changed considerably after the

recent positive endovascular clinical trials; and so is the hospital workflow and treatment site. As a result, the

1
imaging department has become the site of maximum activity during an acute stroke protocol. Time management,

teamwork and standardized institutional protocols contribute to improve functional outcome.

In this review article, we emphasize the critical role an Imaging department’s organization plays in a stroke center

and the workflow involved in management of acute stroke.

Abbreviations:

MR CLEAN- Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the
Netherlands
EMS- Emergency Medical Services
ESCAPE-Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke
EXTEND-IA-Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial
REVASCAT-Endovascular Revascularization with Solitaire Device Versus Best Medical Therapy in Anterior
Circulation Stroke Within 8 Hours
SWIFT-PRIME-Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment
HERMES- Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration
CSC- Comprehensive Stroke Center
PSC- Primary Stroke Center
ASRH- Acute Stroke Ready Hospitals
ASPECTS- Alberta Stroke Program Early CT Score, CTA- CT angiogram, CTP- CT Perfusion, PACS- Picture Archive and
Communication System, tPA- Tissue Plasminogen Activator, IV- Intravenous

Key words: Imaging department, organization, Acute Ischemic Stroke management

Introduction:

Time is critical and non-negotiable for patients with acute stroke. Having a right, well-organized center with

seamless lean workflow for stroke management will contribute immensely towards positive outcomes in patients

with acute stroke. The imaging department is an integral part of the stroke management task force and plays a

critical role in accurate and timely interpretation of images obtained in the emergency department.

Results of each of the recently published clinical trials (MR CLEAN, ESCAPE, SWIFT-PRIME, EXTEND-IA, REVASCAT)

favored emergency endovascular intervention in the management of large proximal vessel occlusions in eligible

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patients in addition to standard care [1-5]. These endovascular trials emphasized the role of imaging in patient

selection and teamwork as the key to success for endovascular therapy.

Here we show the reader the critical role an Imaging department’s organization plays in a stroke center and the

workflow involved in management of acute stroke.

Summary of “The 3-Stroke certifications” for defining the role of acute stroke care centers [6]:

The Joint Commission has implemented a three level certification process based on level of stroke care and

expertise.

Primary stroke centers (PSCs): These centers are equipped to manage most of the acute ischemic stroke, do basic

imaging (including CT/ CTA/ MR/ MRA, cardiac imaging) and laboratory investigations, perform emergency

thrombolysis and access to neurosurgery within 2 hours. Complex cases needing neuro-endovascular or neuro-

critical care are transferred to the nearest comprehensive stroke center (CSC).

Comprehensive stroke care centers (CSCs): Comprehensive stroke centers are typically the largest and best-

equipped hospitals in a given geographical area that can treat any kind of stroke (both ischemic and hemorrhagic)

or stroke complications. The Joint Commission (JC) for Hospital Accreditation in United States and other countries

have adopted the pathway of sequestering stroke patients in CSCs, which possess the necessary personnel and

equipment to provide multimodal treatment. This approach benefits patients and also spares non-CSC facilities

from over-burdening their resources [7].

Acute stroke ready hospitals (ASRH): Recently designed by the Joint Commission for those areas without ready

access to PSCs or CSCs within 60 minutes (which accounts for at least 50% of the population in United States),

these ASRHs will have the ability to perform basic diagnostic imaging (like CT/ MR) round the clock. The acute

stroke team will have the ability to perform thrombolysis if needed, prior to transferring the patient to PSC or CSC

[8].

It is clear from the above discussion, that the diagnostic imaging department plays an indisputable role in stroke

care, regardless of the level of hospital certification for acute stroke management. Hence there is need for re-

3
organization of the radiology departments in these stroke centers in order to impart quality care as per the current

guidelines.

“Time is brain”:

The concept of ‘time is brain’ is not only intuitively obvious but is backed by excellent data [9, 10, 11, 12]. Results

from the IMS III study shows that every 45-minute delay in angiographic reperfusion reduced the likelihood of

good clinical outcome by 10% [9]. The STAR study shows that for every one-hour delay in stroke onset to final

digital subtraction angiography time, there is a 38% decrease in outcome [11]. In ESCAPE trial, every 30-minute

increase in CT to-reperfusion time reduced the probability of achieving a functionally independent outcome by

8.3% . [13]

In a recent meta-analysis of the five successful endovascular clinical stroke trials (HERMES collaboration)

conducted over 89 international sites, each 1-hour delay to reperfusion was associated with a less favorable

degree of disability (cOR, 0.84; ARD, −6.7%) and less functional independence (OR, 0.81, ARD, −5.2%). [14]

In fact, every passing minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers

are destroyed in the territory of occluded artery [15].

Teamwork is the key to success:

While teamwork is critical for success of any business (for example: travel, healthcare, pharma, sports, automobile,

media, etc), it is even more important in situations that are time critical and the outcome is directly correlated with

the efficiency of the overall process. The closest analogy that is commonly used is the changing of the wheels

during an F1 race where in approximately 10 seconds all the wheels of the race car are changed and the

competitor moves on.

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A well-organized collective multi-specialty team work is critical for success. A stroke team consists of specialists

from various departments, inclusive of and not limited to neurology, neuroradiology, neurosurgery, anesthesia and

technical support staff (Figure 1).

Imaging department as the new hub for acute stroke diagnosis and management decision-making:

With the recent change in the treatment paradigm after the positive endovascular clinical trials; there needs to be

a corresponding change in the hospital workflow. The imaging department needs to become the site of maximum

activity during an acute stroke protocol [16]. Starting from patient triaging, image acquisition, image

interpretation, decision-making, discussion and consent taking as well as treatment, almost all of the important

aspects of acute stroke management will take place within the imaging department (Figure 2).

Speed, Efficiency, Consistency, and Teamwork are the basic fundamental principles of imaging department in a

Comprehensive Stroke Centre. These principles echo with the requirements in an acute trauma care set-up, as in

any emergency imaging areas [17].

 Dedicated stroke paging system: Fast and accurate communication within the stroke team plays

a crucial role in acute stroke treatment. Integrating radiologists in this process ensures faster imaging and

interpretation, influencing better clinical outcomes. A 24 x 7 stroke paging system for CT technical staff,

Endovascular team and on-call CT radiologist will enable them to know ahead of time about a potential

acute stroke patient approaching the hospital [16]. This in-turn will ensure availability of the CT scanner

for rapid image acquisition and interpretation. The endovascular team can meanwhile get ready for a

potential endovascular procedure.

 CT as the first line of investigation:

o CT and CT angiogram (CTA): Because of its quick and widely available acquisition, non-

contrast CT remains the primary imaging technique for stroke syndrome presentations. It helps

to quickly differentiate ischemic and hemorrhagic stroke and to measure the extent of early

ischemic changes with ASPECTS (www.aspectsinstroke.com).

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All recent clinical trials used CTA technique to detect proximal intracranial occlusions [1-5].

Additionally, collateral status can be measured on multiphase CTA by assessing backfilling pial

arteries distal to the intracranial occlusion compared with the unaffected contralateral

hemisphere [18]. Recent articles suggest that CT, CTA is now the standard of care in the work up

of acute stroke patients [19].

Imaging department in a stroke center must be equipped with a fully functional Emergency CT

scanner with CTA (preferably multiphase CTA) and possibly CT Perfusion capabilities.

Because acute ischemic stroke treatment is time sensitive, front-line physicians, including stroke

neurologists, general neurologists, emergency room physicians, and trainees have important

roles in image interpretation. A separate dedicated imaging station with access to PACS should

be available round the clock for these non-radiologists to review the CT/ CTA images as soon as

they are acquired. A computer system with access to old health records of the patients should

also be ideally available in the CT area.

o Decision on CT perfusion (CTP): Not all centers have the ability to perform and process

CT perfusion studies. Also, CT perfusion as an imaging modality in acute setting has some

disadvantages, including limited brain coverage, susceptibility to motion, and increased time

consumption for image acquisition, processing and interpretation [20]. Generally, the type of

information from CTP may not influence current clinical decision-making with regard to offering

endovascular therapy [21]. Hence it should be left to the discretion of the Institution regarding

the utilization of this modality, potentially for research purposes. At our centre we do not use

CTP routinely. Based on the recent data, it is clear that centres that do continue to perform CTP

should be able to demonstrate no deterioration in overall workflow and no significant time loss.

o MRI versus CT: Magnetic resonance (MR) imaging has definitive advantages over CT,

including tissue viability assessment with diffusion weighted imaging. However, the availability of

MR imaging in the hyperacute setting is limited [16]. In addition, MR is usually quite time

6
 consuming especially the process of ruling out contraindications to MRI such as pacemakers etc.

Hence radiology department should focus on better organization and workflow improvement in

CT imaging, in a setting of comprehensive stroke care.

 Patient transfer from Emergency to CT scanner: Importance of Time-metrics

The Joint Commission already mandates that unenhanced CT of patients suspected of having acute

ischemic stroke be performed within 25 minutes of admission to the emergency department and that

unenhanced CT scans be interpreted within 20 minutes of being obtained. These targeted times should be

even further shortened in CSCs. The “ideal” times suggested by the Society of Neurointerventional

Surgery are door-to–unenhanced CT scan interpretation of less than 15 minutes and door-to–CT

angiogram interpretation of less than 20 minutes [22].

In an ideal scenario, patient may be transferred from “Door-to-Scanner”, by-passing the Emergency

department. In this way, patient can be transferred directly on the EMS stretcher to the scanner. Clinical

examination can be performed on the EMS stretcher while transferring to the CT scanner. Detailed

patient clinical history from the EMS paramedical staff can also be obtained during the transfer, ensuring

no delays [23].

 Protocol-driven image acquisition:

Clear written imaging protocols should be available with the CT technologists for non-contrast CT and CT

angiogram of head and neck vessels. These protocols should be uniform across the regional stroke

network. At our institution, we have a standard ‘acute stroke protocol’ consisting of a plain CT head and a

multiphase CTA (the first phase includes arch and neck vessels). The details of this protocol have been

previously described [18]. We do not hold up doing a CTA for availability of kidney function tests. There is

literature data available to suggest that there is no significant difference in the incidence of acute renal

injury between contrast enhanced and non-enhanced CT scans, irrespective of the baseline renal function

[24].

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 Round-the-clock availability of experienced radiologist and CT technologist:

The requirement of round-the-clock availability of an experienced CT technologist with proficiency in

performing CTAs and CT perfusion is not to be ignored. In many institutions, 24x7 availability of a trained

neuroradiologist may not be feasible [25]. In such scenarios, the staff radiologist on duty must be capable

of rapidly interpreting changes of acute ischemic stroke on non-contrast CT (preferably give ASPECTS

scoring) and identify vascular occlusion on CT angiography [16]. Radiology departments must focus on

continuous training to further improve efficiency of stroke treatment and accurate and timely image

interpretation. In many institutions, residents (and fellows) play a key role in emergency radiology

services especially after hours. In light of the recent data, it is imperative that radiology residency

programs adapt to these changes in workflow and create a curriculum to have effective, accurate and

timely interpretation by residents. At our institution, we focus on teaching residents interpretation of

acute stroke studies in the first year of residency. Our experience suggests that residents find multiphase

CTA extremely useful for quickly detecting the site of occlusion, assessing collaterals and correlating these

with the findings on the non-contract CT scan [26].

 Efficient communication within team and quick decision making:

Quick review of plain CT head images to rule out intracranial hemorrhage and large ischemic core, while

the patient is still in the scanner, enables immediate decision regarding administering intravenous tPA.

This time can be utilized for the preparation and administration of intravenous tPA, which can be started

simultaneously in the CT suite [23].

 Transfer of patient to Angiogram suite:

Historically, the workflow around IV (Intravenous) rtPA administration has been time-consuming as it was

administered in a dedicated space away from the angiography suite and sometimes patients were

assessed for clinical improvement before notifying the endovascular team [27]. The recent trials have

however proven that endovascular therapy is effective with or without IV rtPA. Hence it is not imperative

8
 to wait for clinical improvement, and the patient should be transferred as soon as possible to the

angiography suite.

 Organization of workflow within the Angiogram suite:

It is ideal to have a prearranged stroke tray ready for use in the angiogram suite at all times so that the

procedure can be initiated without delay [23]. We also emphasize using standardized techniques and

devices as much as possible [28]. We have implemented what we call BRISK (Brisk Recanalization Ischemic

Stroke Kit). It comprises of a stroke tray where all the necessary materials are already set up (in the order

of when they would be needed) and ready to go (excluding expensive materials such as stent retrievers).

We implemented this widely across the ESCAPE trial sites as part of the ESCAPE quality improvement and

workflow efficiency process. All the recent trials have used new generation stent retrievers in majority of

cases [1-5]. Different centers may use different techniques in stroke intervention (For example: Use of

anesthesia, use of balloon guide catheter, use of intermediate aspiration catheter etc.) depending on their

comfort level. It is advisable to stick to the Institution protocol as much as possible to avoid confusions

among the team members and time delay. Cross-training x-ray and CT technicians to help in the

angiography suite may speed up the process on weekends or during nights [23]. As most of the hospitals

have 24x7 availability of an x-ray and/or CT technologist, it’s a good idea to train them in the basic angio-

suite procedures. Knowledge about putting-on the angio-machine, entering the patient demographics

into the angio-console, positioning the patient on angio-table, location of important devices and materials

like contrast, heparin etc can avoid delays while waiting for the endovascular team to arrive.

Some General Recommendations

o On physical restructuring, documentation, quality control & process improvement of the

Imaging department in a stroke set up:

 Physical restructuring: Institutions working as comprehensive stroke centers need to physically

restructure the radiology department. The emergency CT scanner must be located in very close

proximity to the emergency department. Separate image reviewing stations for 24 x7 access to stroke

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 team should be made available for seamless workflow. Emergency CT reading rooms should be

placed closer to the scanner, so that real time protocoling and decision on repeating the scan can be

taken without delay by the on-call radiologist. Finally, the neuroangiography suite can be favorably

located in close proximity to the CT scanner, for faster patient mobilization [16].

 Documentation: Onset-to-reperfusion time and imaging-to-reperfusion time are the two critical

steps in the stroke management and recent endovascular trials have demonstrated that fast

reperfusion is the key to a good outcome. Centers should keep detailed time records of their

workflow and times for image acquisition, transfer, post-processing, and interpretation.

 Quality control: Regular internal audits to self-assess the department performance is

recommended.

 Process improvement: Regular inter-departmental meetings involving the radiology, neurology

and neurosurgical team to discuss and challenge the existing stroke patient management with

regards to outcomes is beneficial.

Conclusion

A well-organized Imaging department plays a critical role in stroke center contributing seamlessly for the

management of acute stroke patients thereby improving functional outcome. Challenging workflow at regular

intervals with iterative feedback and aggressive time goals will further enhance efficient workflow environments.

Having standardized and simple imaging protocols and investing early in resident education are critical steps for

workflow efficiency. We recommend a simple imaging protocol of non-contract CT and multiphase CTA.

Conflicts of Interest:

Zarina Assis has no conflict of interest.

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Acknowledgements

We would like to thank all the members of the Calgary Stroke Program for the excellent team work.

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Biography

Bijoy K Menon reports membership of the steering and executive committee, ESCAPE trial that received
support from Covidien Inc., site principal investigator, SOCRATES Trial, sponsored by AstraZeneca,
honoraria from Penumbra Inc., a provisional patent 62/086077 for triaging systems in ischemic stroke,
research funding from CIHR, HSFC, AIHS, HBI, and the Faculty of Medicine, University of Calgary, and
reports board membership of QuikFlo Health Inc.

Mayank Goyal is a consultant for Covidien for teaching engagements and for design and conduct of
SWIFT PRIME trial; University of Calgary received partial funding for ESCAPE trial provided by Covidien
through an unrestricted grant to the institution. Dr. Goyal has a patent systems and methods for
diagnos-
ing strokes (PCT/CA2013/000761) licensed to GE Healthcare.

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Figure Legends:

Figure 1: Pictorial representation of stroke management being multi-departmental and the need for team-work.

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Figure 2: Infographic representation of role of imaging department in acute stroke management.

18