Access to Thrombolysis for Non-Resident and Resident Stroke Patients—A Registry-Based Comparative Study from Berlin

Abstract

ObjectivesStroke can happen to people away from home. It is unknown whether non-resident and resident stroke patients have equal access to thrombolysis.Materials and methodsConsecutive patients cared for by the Stroke Emergency Mobile between 2011 and 2016 after prompting suspicion of acute stroke during the emergency call were included in our registry. Patients were categorized as residents or non-residents based on their main address. Clinical characteristics, thrombolysis rates, and time intervals from symptom onset/last seen well to alarm and to thrombolysis were compared between groups adjusting for age, pre-stroke modified Rankin Scale (mRS) score, and National Institutes of Health Stroke Scale (NIHSS) score.ResultsOf 4,254 patients for whom a stroke dispatch was activated, 2,451 had ischemic or hemorrhagic strokes, including 73 non-residents. Non-resident stroke patients were younger (median 69.4 vs. 76.6 years, p < 0.001), had less pre-stroke disability (mRS ≥ 2:17.8 vs. 47.5%, p < 0.001) and less severe strokes (median NIHSS 4 vs. 5, p = 0.02). Thrombolysis rates were higher in non-residents (30.9 vs. 22.0% of ischemic stroke patients, p = 0.04) and emergency calls were made faster (symptom onset/last-seen-well-to-alarm time 35 vs. 144 min, p = 0.04). A lower proportion of non-residents had unknown time of symptom onset (21.9 vs. 46.4%, p < 0.001). For patients with known time of symptom onset, thrombolysis rates, and prehospital delays were similar among non-residents and residents.ConclusionIn this study, non-resident stroke patients had higher rates of thrombolysis than residents. This may be explained by a lower proportion of patients with unknown time of symptom onset.

Shifting acute stroke management to the prehospital setting

“…In cases of high certainty, for example, with a very low rapid arterial occlusion evaluation scale (RACE) score, direct transfer to the tertiary hospital (mothership concept) may be reasonable. Very high RACE scores suggest a benefit of gearing towards the nearest primary center, starting tPA there and additional transport only in case of proven large vessel occlusion (drip-and-ship) [23]. However, the prehospital use and reliability of the different stroke scales to make these decisions are widely debated [24] and a large trial comparing drip-and-ship and mothership models has not shown superiority of either approach [25,26].…”