Improving thrombolysis for acute ischemic stroke in Lombardia stroke centers

Abstract

The purpose of this study is to identify which factors are able to limit or hamper the access to systemic thrombolysis (evTPA) in Lombardia to define corrective interventions. We analyzed 1,015 patients with ischemic stroke admitted to emergency departments (ED) participating to the Lombardia Stroke Unit Registry and eligible for evTPA; 303 (29.9%) patients were treated with evTPA (evTPA+ group) and 712 (70.1%) were not (evTPA- group). We collected case-mix and stroke care process variables.The evTPA+ group was characterized by a shorter ED arrival time, a greater neurological impairment, a more chance to be admitted to ED linked to comprehensive stroke center (CSC) and a shorter waiting time to access to diagnostic procedures. The chance to be treated with evTPA was greater if neurological evaluation anticipated neuroimaging (p = 0.0003). The multivariate analysis confirmed that the admission to ED linked to CSC (OR: 2.50, 95% CI: 1.39-4.48, p < 0.0001) and neurological evaluation performed before neuroimaging (OR: 2.34, 95% CI: 1.35-4.04, p = 0.002) increased the probability to receive rtPA. The evTPA treatment is strictly dependent on pre-hospital and ED care process phases and strongly influenced by the degree of stroke severity. Door-to-needle time is shorter in patients with a greater stroke severity and a shorter ED arrival time. A 24-h/week availability of the neurologist in ED can increase the percentage of thrombolysis optimizing the selection of patients and the timing of the diagnostic procedures.