Pre- and in-hospital delays from stroke onset to intra-arterial thrombolysis

Abstract

Nedeltchev K, Arnold M, Brekenfeld C, et al (University Hospital of Bern, Bern, Switzerland) Stroke. 2003;34:1230-1234 Intravenous recombinant tissue plasminogen activator (rtPA) has been shown to be an efficacious treatment for acute ischemic stroke when administered within 3 hours of the onset of stroke. Three large randomized trials that examined intravenous rtPA treatment beyond 3 hours failed to demonstrate a clear benefit on intention-to-treat analyses. However, secondary analyses of the data from 2 of these trials and a Cochrane meta-analysis suggest that rtPA is beneficial up to 6 hours after the onset of stroke but is less beneficial than within the 3-hour time window. It was also found that intra-arterial treatment with recombinant prourokinase significantly improved clinical outcome when administered up to 6 hours after stroke onset. The time intervals preceding intra-arterial thrombolysis were examined to accelerate and optimize the management of acute stroke. The study was set in the stroke center of a tertiary care center in Bern, Switzerland, and enrolled 597 patients with acute stroke who were admitted from January 1, 2000, to April 30, 2002. Data prospectively recorded and analyzed included the time of symptom onset; admission; computed tomography (CT) or magnetic resonance imaging scan, or both; diagnostic arteriography; and, if performed, intra-arterial thrombolysis. The mean time to arrival in the emergency department was 99 minutes for patients admitted directly (Bern patients), 127 minutes for patients who were referred from community hospitals without a CT scanner (non-Bern/–CT patients), and 210 minutes for patients from hospitals with imaging facilities (non-Bern/+CT patients). The mean delay from symptom onset to treatment was 234 minutes for the Bern patients, 269 minutes for the non-Bern/–CT patients, and 302 minutes for the non-Bern/+CT patients. Patients in the non-Bern/+CT group required more time to receive intra-arterial thrombolysis than did patients who were admitted directly or who were transferred from a hospital without a CT scanner. Direct referral without prior imaging at community hospitals shortens the time until intra-arterial thrombolysis. The inhospital delay preceding intra-arterial thrombolysis at the study institution was found to be longer than delays reported for intravenous thrombolysis and thus indicated a potential for improvement.