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.
Highlights
One-fifth of ischemic strokes occur in the posterior circulation [1]
To estimate the number of patients lost for recombinant tissue-plasminogen activator (rt-PA) treatment due to PCSrelated delay, we multiplied the number of posterior circulation strokes (PCS) with the difference of the rates of rt-PA treatment: NPCS 9 (RACS - RPCS) where N is the number of patients and R is the rt-PA-rate. rt-PA rates changed over the study period and we used data of the last two years only for this computation
Patients with PCS had a significantly longer ODT compared to anterior circulation strokes (ACS): median: 170 min (25th percentile: 79 min, 75th percentile: 420 min) versus 110 (60, 240); p \ 0.001 (Table 1)
Summary
Compared to anterior circulation strokes (ACS) percentage of patients with posterior circulation strokes (PCS) receiving intravenous recombinant tissue-plasminogen activator (rt-PA) was lower across different stroke registries even though approval does not exclude specific localizations such as posterior circulation [2,3,4,5]. This difference might be influenced by underrepresentation of PCS in randomized controlled trials [6,7,8,9,10]. Uncertainties in relation with transient symptoms related to the posterior circulation can result in lower rates of diagnosis of TIAs [16] Misdiagnosis and delays may have significant implications for treatment and could have potential medicolegal consequences
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