Thrombolytic therapy for acute stroke (<3 hours) will not have a major impact on death
and dependency unless it is accessible to more patients.
To determine why patients with ischemic stroke did not receive IV TPA and assess the
availability of this therapy to patients with ischemic stroke.
Consecutive patients with acute ischemic stroke were prospectively identified at a
university teaching hospital between October 1996 and December 1999. Additional patients
with ischemic stroke were identified that were admitted to one of three other hospitals
in the Calgary region during the study period. The Oxford Community Stroke Programme
Classification was used to record type and side of stroke.
Of 2165 stroke patients presenting to the university hospital, 1168 (53.9%) were diagnosed
with ischemic stroke, 31.8% with intracranial hemorrhage (intracerebral, subarachnoid,
or subdural), and 13.9% with TIA. Delay in presentation to emergency department beyond
3 hours excluded 73.1% (854/1168). Major reasons for delay included uncertain time
of onset (24.2%), patients waited to see if symptoms would improve (29%), delay caused
by transfer from an outlying hospital (8.9%), and inaccessibility of treating hospital
(5.7%). Twenty-seven percent of patients with ischemic stroke (314/1168) were admitted
within 3 hours of sympton onset and of these 84 (26.7%) patients received IV TPA.
The major reasons for exclusion in this group of patients (<3 hours) were mild stroke
(13.1%), clinical improvement (18.2%), perceived protocol exclusions (13.6%), emergency
department referral delay (8.9%), and significant comorbidity (8.3%). Of those patients
who were considered too mild or were documented to have had significant improvement,
32% either remained dependent at hospital discharge or died during hospital admission.
Throughout the region there was a total of 1806 ischemic stroke patients (admitted
to all four Calgary hospitals). During this study period, 4.7% received IV TPA.
The majority of patients are unable to receive TPA for acute ischemic stroke because
they do no not reach the hospital soon enough. Of those patients presenting within
3 hours, 27% received the therapy but a further 31% were excluded because their symptoms
were either considered too mild or were rapidly improving. Subsequently, a third of
these patients were left either dependent or dead, bringing into question the initial
decision not to treat.