Authors (including presenting author) :
Raymond Leung (1), Kelvin Tsoi (2), Karin Chow (1)
Affiliation :
(1) Stroke Nursing Team, Department of Medicine and Geriatrics, Tuen Mun Hospital
(2) Neurology Team, Department of Medicine and Geriatrics, Tuen Mun Hospital
Introduction :
Door-to-Needle (DTN) time is a crucial indicator of hyperacute stroke thrombolysis (TPA) service. International guidelines recommend DTN time within 60 minutes, while National standard aim for 45 minutes. Studies have shown that shorter DTN times improve functional outcomes in ischemic stroke patients. Although guidelines do not mandate chest X-ray (CXR) before thrombolysis, it is routinely performed in many hospitals due to concerns regarding acute aortic syndrome (AAS). A recent audit by the TMH stroke team found that, despite collaboration with radiology department, the need for CXR extended DTN time by an average of 15 minutes. This delay is suboptimal for meeting standards and may adversely affect patient outcomes.
Objectives :
To explore the feasibility of omitting routine CXR in hyperacute stroke patients eligible for thrombolysis.
Methodology :
A team of neurologists and stroke nurses reviewed records of all stroke patients who underwent TPA screening at TMH over the past three years. Patients suspected of having AAS were identified, and their CXRs taken during TPA screening were assessed. A literature review identified alternative screening methods for AAS that do not involve CXR.
Result & Outcome :
2,862 case records were reviewed, identifying 33 cases (1.15%) with suspected AAS. Only 6 patients (0.21% of all CXRs performed) showed radiological features suggestive of AAS on their initial CXR. The literature review indicated similarly low sensitivity of CXR for screening potential AAS.
The literature supports using three clinical questions to assess AAS risk:
-High-risk clinical history, including Marfan syndrome or recent aortic manipulation;
-Clinical features such as sudden onset of chest, back, or abdominal pain;
-Presence of perfusion deficits, including pulse deficits or bilateral arm blood pressure differences.
Patients with any of these signs should have direct CT aortograms for AAS screening.
TMH piloted this workflow since December 2024, achieving marked reduction in DTN time from 45 to 36 minutes. One patient with suspected AAS was screened out via clinical history, and confirmed negative for AAS by CT aortogram. No adverse event related to AAS were observed.
This demonstrates the potential of omitting CXR in hyperacute stroke workflows, enhancing clinical efficiency and improving patient outcomes while maintaining safety in stroke thrombolysis.
