Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
Highlights
The “time is brain” concept introduced more than two decades ago [1] encapsulates the crucial importance of time in treating acute stroke
A study analyzing the baseline penumbra volume, baseline ischemic core volume, and the penumbra salvaged from infarction after thrombolysis, showed that greater penumbral salvage had the greatest effect on disability-free life, rather than onset to treatment time [14]
The following were excluded: studies focusing solely on transient ischemic attacks (TIA); studies that reported on hospital arrival times but did not analyze factors associated with early or delayed arrival; studies on decision delay after stroke; studies on delay to alerting medical services or delay to first medical contact, and delay to admission to stroke unit; and studies on factors associated with Emergency Medical Services (EMS) use
Summary
The “time is brain” concept introduced more than two decades ago [1] encapsulates the crucial importance of time in treating acute stroke. A study analyzing the baseline penumbra volume, baseline ischemic core volume, and the penumbra salvaged from infarction after thrombolysis, showed that greater penumbral salvage had the greatest effect on disability-free life, rather than onset to treatment time [14] This does not negate the importance of early presentation in this context, as it allows more time for prompt clinical and imaging assessment. We conducted a review of studies that analyzed factors associated with either early or delayed hospital arrival after stroke, with the aim of identifying modifiable targets of interventions in reducing prehospital delay Knowledge of these factors may be helpful in reducing onset-to-door times, and increase the implementation rates of acute stroke therapies
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