Negative mechanical thrombectomy (MT) trials (IMS III, MRRESCUE, Synsthesis expansion) resulted in very cautious selection of patients who underwent thrombectomy which probably caused delay in deciding neurointervention. With positive results of the Big Five trials, MT within 6 hours became standard of care. DAWN broadened the horizon of MT to 24 hours of last known normal. To expedite MT at our community hospital we have implemented Code Neurointervention in addition to Code Stroke. 

Retrospective analysis of patients who received MT at our comprehensive stroke center from January 2014 till July 2018 was done. Patients were divided in three groups: A) Pre Big Five Trials era (Jan 2014 –Dec 2014), B) Post Big Five but pre-DAWN era (Jan 2015 – May 2017) and C) Post-DAWN era (Jun 2017 – July 2018). We compared the time interval between Code stroke and Code Neurointervention (in minutes) among these three groups. Code Stroke: time when a patient with acute neurological change within last 24 hours is encountered. Code Neurointervention: time when Vascular Neurologist and Neurointerventionalist decide to pursue endovascular therapy.

Out of 2423 ischemic stroke patients, 262 received endovascular therapy. Group A (n=38, males=18, mean age =68); group B (n=137, males=67, mean age=68); group C (n=87, males=47, mean age=71). It took about about 110 minutes to decide neurointervention in group A (SD – 70; 95 CI – 88 -133), 72 minutes in group B (SD -50; 95 CI – 67 -81) and 64 minutes in group C (SD – 40; 95 CI – 54 -73). All intergroup differences were statistically significant (p value < 0.05).

Accumulation of recent evidence based data has progressively and significantly reduced the time to decision for neurointervention.  Improvement in time efficiency is probably multifactorial.