Utilization of Intravenous Tissue Plasminogen Activator and Reasons for Nonuse in Acute Ischemic Stroke in Saudi Arabia

Abstract

Background: Recombinant tissue plasminogen activator (rt-PA, alteplase) within 4.5 hours of symptom onset decreases the rate of disability after acute ischemic stroke (AIS). Due to various reasons, alteplase remains underutilized in certain regions (∼3% in low- and middle-income countries). Aims: We aimed to estimate the alteplase utilization rate and identify the reasons for nonuse in Saudi Arabia. Methods: We retrospectively reviewed all patients admitted with suspected stroke in the past 24 hours to the stroke unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia from February 2016 to July 2018. We estimated the alteplase utilization rate among patients with AIS who could be treated within 4.5 hours of symptoms onset (≤225 minutes, allowing 45 minutes for door to needle time). We examined potential predictors of alteplase use using multivariable logistic regression analyses. Study was approved by local IRB. Results: Of 1366 patients with suspected stroke, 819 (60%) had AIS. The alteplase utilization rates were 8.6% and 29% for all AIS and AIS arrived within the therapeutic window, respectively. The most common reason for no alteplase treatment was late arrival. Only 244 (29.8%) of AIS patients arrived within the time window for treatment. Among patients with sudden neurological deficit who arrived within the therapeutic time window, the most common reasons were mild neurological deficit (National Institutes of Health Stroke Scale score <5, 29.9%), stroke mimics (16.6%), and hemorrhagic stroke (8.1%). Conclusions: Our study showed a comparable alteplase utilization rate with most international estimates. The low utilization rate was mainly attributed to late patient arrival. Urgent interventions are needed to improve public awareness of stroke recognition and prehospital stroke care.