Extending Tissue Plasminogen Activator Use to Community and Rural Stroke Patients

Abstract

Background and Purpose-Guidelines for intravenous tissue plasminogen activator (tPA) use in stroke emphasize the importance of limiting its use to facilities with imaging capabilities and stroke expertise. This prospective case series set out to evaluate the safety of tPA use in patients referred from rural communities to a tertiary center. Methods-Prospective data of 82 consecutive patients treated with tPA in London, Ontario, were reviewed. Results-Twenty-three patients were transferred to London from a rural hospital (non-London patients); 49 were first evaluated in a London emergency room (London ER); and 10 were inpatients in a London hospital at the time of stroke onset. Mean transfer time and distance to London for non-London patients were 89 minutes and 41 miles. Although symptom onset to London ER times were longer for non-London than for London ER patients (123 versus 53 minutes), the door to needle times were significantly shorter for the former (49 versus 95 minutes, PϽ0.005). Imaging to needle times were longer for London inpatients compared with London ER patients (55 versus 36 minutes, Pϭ0.16). The proportion of patients with Ͼ4-point improvement on the NIH Stroke Scale or cure at 24 hours was 57%, with no difference among groups (Pϭ0.46). The overall symptomatic hemorrhage rate at 36 hours was 2%. No significant differences in outcomes were observed at 3 months. Conclusions-This prospective study suggests that it is feasible and safe to treat rural patients referred to a tertiary care center with tPA, thus extending the benefits of thrombolysis for acute stroke to a wider population. Key Words: Canada Ⅲ stroke, acute Ⅲ stroke management Ⅲ thrombolytic therapy Ⅲ tissue plasminogen activator T he National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Study Group showed in 1995 that intravenous tissue plasminogen activator (tPA) was an efficacious treatment for acute ischemic stroke. 1 Since its approval by the FDA in 1996, tPA has been used safely and effectively in routine clinical practice in urban academic medical centers 2-7 and in community hospitals. 2,8 Strategies to extend thrombolysis to rural community hospitals with imaging and intensive care facilities but with limited stroke expertise 5,9 and referral protocols for urban community hospitals that have limited access to imaging facilities 10 have been implemented successfully.Guidelines have been developed to ensure safety in the use of tPA for acute ischemic stroke. [11][12][13] Routine tPA use is currently restricted to those patients who can be treated within 3 hours of symptom onset. All the guidelines emphasize the importance of involving physicians with expertise in the diagnosis of stroke and in the interpretation of CT scans and restrict treatment to facilities that have the ability to handle hemorrhagic complications. Many hospitals, particularly outside the United States, 10,14 lack the staff or the facilities required to meet these criteria.In February 1999, the Health Protection Branch of Canada granted a ...

Stroke Thrombolysis: Having More Time Translates Into Delayed Therapy

“…Three small-scale studies including a total of 502 patients reported a similar inverse association between ODT and DNT, yet the magnitude of time delay in these evaluations, conducted between 1997 and 2002, was more pronounced. [12][13][14] Moreover, recent analysis of data from "Get With The GuidelinesStroke" hospitals (presented at the 2009 International Stroke Conference but not yet published in full) 11 yielded a treatment delay highly consistent with that observed in our survey.…”

A Telestroke Network Enhances Recruitment into Acute Stroke Clinical Trials

“…However, for intracerebral hemorrhage and ischemic stroke, time lost in transportation to the hub results in delays to enrollment and limits participation analogous to what was seen clinically in the ship and drip paradigm of tPA delivery for acute ischemic stroke patients in remote EDs. 14,15 This could be overcome by enrolling patients at the spokes and initiating research protocols before arriving at the hub. Although not all therapies would be feasible in this scenario, administration of a putative neuroprotectant may be possible.…”

Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

“…12,14,[17][18][19][20][21] It has also been shown that educational programs for both the public and physicians increase the number of patients arriving at the hospitals within the time limits for thrombolysis. 22 In US stroke centers, up to 59% of the patients who presented within 24 hours of symptom onset arrived within 3 hours.…”

“…Similar analyses have already been performed for intravenous treatment. [17][18][19][20]27 Patients who were transferred directly to our stroke center were mostly residents of Bern or an area close to that vicinity. Their mean prehospital delay was 99 minutes.…”