Prehospital and intra-hospital time delays in posterior circulation stroke: results from the Austrian Stroke Unit Registry

Abstract

Therapeutic effect of recombinant tissue-plasminogen activator (rt-PA) is time dependent. There is limited evidence whether localization of stroke within the posterior circulation (PCS) is associated with a treatment delay. We aimed to analyze within a nationwide multicenter cohort whether duration of pre- and intra-hospital patient management differs between patients with PCS and anterior circulation strokes (ACS). We studied onset-to-door-times (ODT) and door-to-needle-times (DNT) of all patients with acute ischemic stroke (IS) enrolled in the Austrian Stroke Unit Registry according to infarct localization. Classification into PCS and ACS was based on clinical presentation applying the criteria used in the Oxfordshire Community Stroke Project. Relationships between ODT, respectively, DNT and explanatory variables were modeled by multivariate linear regression. Between 2003 and 2015, 71010 patients with IS were enrolled, 11,924 with PCS and 59,086 with ACS. Overall, the ODT was significantly longer in PCS: median (IQR): 170 (25th, 75th‰: 79,420) min versus 110 (60,240); p < 0.001; this finding held true in multivariable analysis. In 10535 rt-PA-treated patients (1022 PCS/9832 ACS), ODT and DNT were significantly longer among those with PCS: ODT: median: 80 min (55,120) versus 72 (50,110), p < 0.001; DNT: 57 (35.90) versus 45 (30.67), p < 0.001. In the multivariate model, PCS was significantly associated with delay in the DNT. In conclusion, in this large nationwide cohort, patient management was significantly slower in PCS as compared to ACS. Increasing awareness about these delays and further elaboration of the underlying causes may translate into higher proportions of patients with PCS receiving rt-PA.Electronic supplementary materialThe online version of this article (doi:10.1007/s00415-016-8330-x) contains supplementary material, which is available to authorized users.

Thrombectomy in posterior circulation stroke: differences in procedures and outcome compared to anterior circulation stroke in the prospective multicentre REVASK registry

“…In the study of Sarikaya and co‐workers , time to treatment did not differ between patients treated with IVT for PCS and ACS, whilst other studies reported a significantly longer onset to needle time . In the present analysis, all relevant diagnostic and treatment‐related time periods were significantly longer in PCS patients treated with MT.…”

Epidemiology, Natural History, and Clinical Presentation of Large Vessel Ischemic Stroke

“…Posterior circulation LVOs are often more challenging to diagnose than LVOs of the anterior circulation due to a nonspecificity of associated symptoms, which can lead to significant delays in both prehospital and intrahospital management of this patient subset. 35 Nonetheless, common symptoms seen with occlusion of the VAs and BA include hemibody weakness or numbness, dizziness, nausea, vomiting, gait and balance issues, or alterations in consciousness. 36 Occlusions of the PCA typically result in contralateral vision changes such as a homonymous hemianopsia or quadrantanopia.…”

Posterior circulation ischaemic stroke

“…Posterior circulation strokes have longer “door to needle” times for intravenous thrombolysis than anterior circulation strokes,1617 and are more likely to arrive in hospital after the 4.5 hour “time window” for thrombolysis 18…”