Factors influencing nonadministration of thrombolytic therapy in early arrival strokes in a university hospital in Hyderabad, India

Abstract

Background:It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy.Objective:The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them.Materials and Methods:Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed.Results:Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2).Conclusion:One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.

Quality indicators of intravenous thrombolysis from North India

“…D-CT time in the current study was longer than three studies reported from India. [ 9 13 19 ] These were 17 (10–30) min, 31 ± 25.6 min, and 24 (10–47) min, respectively. The delay most commonly occurs when relatives are reluctant to make a decision about admitting and imaging the patient.…”

“…Similar thrombolysis rate has been reported from a center in Hyderabad, India (89/2593, 3.4%). [ 13 ] From another center in Northwest India, the thrombolysis rate was 31.87% (189/593). However, the authors had calculated the percentage using eligible patients instead of all stroke patients.…”

“…[ 9 ] Mean O-D time in the current study was longer than the previous report from our center[ 11 ] but less than that of other reports from India. [ 13 19 ]…”

“…[ 23 ] Similar reasons for not thrombolysing eligible patients were observed in other studies from India. [ 9 11 13 ]…”

Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective

“…Financial constraints were a big contributor, as has been observed in other studies in the country. 29 – 31 Thrombolytic agents are costly, particularly in private institutions. An Indian study reported 16% stroke patients who were eligible for TLT could not afford the therapy due to its high cost.…”