Prehospital Thrombolysis Research Articles

TCTAP A-019 Early Outcomes in Patients Presenting for Acute ST-elevation Myocardial Infarction and Managed by Prehospital Thrombolysis: Results from a Tunisian Single Center Registry

Prehospital thrombolysis (pHT) is recommended by the European Society of Cardiology (ESC) as a surrogate to primary percutaneous coronary intervention (pPCI) in acute ST-elevation myocardial infarction(STEMI) when transfer delays are long. We sought to study early outcomes in patients presenting for

Correction to: Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency.

In the article by Nolte et al, “Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency,” …

ST-Segment Elevation Acute Myocardial Infarction Prehospital Thrombolytic Therapy: Chinese Expert Consensus

Acute myocardial infarction (AMI) still seriously threatens the health of the people in our country. The situation is even more severe in the vast urban and rural areas in China. Timely treatment of AMI patients to reduce mortality and protect heart function is very important. Prehospital thrombolysis treatment has great significance in urban and rural areas outside the big cities. To this end, the Chinese Medical Doctor Association's chest pain professional committee and the Chinese Medical Rescue Association's Cardiovascular Emergency Sub-Commission organized relevant experts to formulate this consensus, aiming to help prehospital medical emergency personnel select the best treatment strategies for patients with AMI. However, the final decision on a specific patient should be made by the prehospital emergency personnel together with the patients and their family members.

Percutaneous Coronary Interventions in Patients with ST-segment Elevation Myocardial Infarction and Totally Occluded Culprit Artery after Pre-hospital Thrombolysis

Percutaneous Coronary Interventions in Patients with ST-segment Elevation Myocardial Infarction and Totally Occluded Culprit Artery after Pre-hospital Thrombolysis

Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study

BackgroundAcute ischemic stroke (AIS) is a medical emergency. The outcome is closely linked to the time elapsing from symptom onset to treatment, and seemingly small delays can mean the difference between full recovery and physical and cognitive dysfunction. Recanalization to allow blood to reenter the affected area is most efficient immediately after symptoms occur, and intravenous thrombolysis must be initiated no later than 4.5 hours after the symptom onset. A liable diagnosis is mandatory to administer the appropriate treatment. Prehospital diagnosis and, in cases where contraindications are ruled out, prehospital initiation of intravenous thrombolysis have been shown to significantly decrease the time from alarm to the treatment.ObjectiveThe objective of this paper is to investigate the effectiveness of prehospital thrombolysis as measured by (1) time spent from symptom onset to treatment and (2) the number of patients treated within 4.5 hours. In addition, we want to conduct explorative studies. These will include (1) the use of biomarkers for diagnostic and prognostic use where we will collect blood samples from various time points, including the hyperacute phase and (2) the study of magnetic resonance imaging (MRI) images at day 1 to determine the infarct volume and if the time to thrombolysis has an influence on this.MethodsThis is a prospective controlled intervention study. The intervention will involve a computed tomography (CT) and thrombolysis in a physician-manned ambulance called a mobile stroke unit (MSU). The control will be the conventional pathway where the patient is transported to the hospital for CT, and thrombolysis as per current procedure.ResultsPatient inclusion has started and a total of 37 patients are enrolled (control and intervention combined). The estimated time to completed inclusion is 36 months, starting from May 2017. The results of this study will be analyzed and published at the end of the trial.ConclusionsThis trial aims to document the feasibility of saving time for all stroke patients by providing prehospital diagnostics and treatment, as well as transport to appropriate level of care, in a safe environment provided by anesthesiologists trained in prehospital critical care.Trial RegistrationClinicalTrials.gov NCT03158259; https://clinicaltrials.gov/show/NCT03158259 (Archived by WebCite at http://www.webcitation.org/6wxNEUMUD)

Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency

Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily -independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency. This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression. Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69-159; STEMO) and 135 (interquartile range, 98-184; CC; P<0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%; P=0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (P=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02-3.87; P=0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95-3.16; P=0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%; P=0.167). The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02358772.

Abstract WP226: Bypassing Interhospital Transfers for Large Vessel Occlusions in the Era of Mobile Stroke Units

Introduction: Mobile stroke units (MSU) provide prehospital intravenous thrombolysis (IVT) for patients with acute ischemic strokes and transport to thrombectomy-capable stroke centers. Door-in-door-out (DIDO) time is recognized as a measure of efficient workflow for interhospital transfer of patients for thrombectomy. We applied this measure to the MSU and compared with our Primary Stroke Center (PSC) transfer process in patients presenting with large vessel occlusions. Methods: We identified 50 patients who underwent thrombectomy for large vessel occlusion in a retrospective review. Mode of transport included MSU (n=18), conventional ambulance from PSC to Comprehensive Stroke Center (CSC) (n=19), or directly presenting to a CSC (n=13) in 2016-2017. Measured outcomes included times for PSC DIDO, MSU DIDO (MSU door to scene departure), door-to-CT, door-to-needle (DTN), and door-to-groin. Results: Among thrombectomy patients, IVT was more likely to be administered in a MSU (55.6%, n=10), than either a PSC (36.8%, n=7) or CSC (38.5%, n=5). Door-to-CT completed times were significantly lower in the MSU versus PSC (27 vs. 44 minutes, p&lt;0.01). DTN times in MSU were significantly shorter than PSC DTN times (27 vs. 56 minutes, p&lt;0.01), as were the median DTN times between CSC vs. PSC (27 vs. 56 minutes, p=0.09). Median DTN times comparing CSC vs. MSU were the same (27 minutes, p=0.33). DIDO time was reduced for MSU patients compared to PSC patients (27 vs. 87 minutes, p&lt;0.01). Door-to-groin times for MSU patients compared to PSC patients was significantly reduced (97 minutes vs. 171 minutes, p&lt;0.01). Door-to-groin times for CSC patients were comparable to MSU patients (100 minutes vs. 97 minutes, p=0.97). Conclusion: Advanced stroke systems of care which include a MSU are highly efficient in both IVT and transport for potential thrombectomy among patients presenting with large vessel occlusion. We introduce a concept of a MSU functioning as a mobile PSC, thus bypassing interhospital transfers.

Abstract TP223: Then and Now: Temporal Evolution of a Mobile Stroke Unit

Introduction: Mobile stroke units (MSU) deliver pre-hospital intravenous thrombolysis (IVT) to patients with acute ischemic stroke. We hypothesize that time efficiencies with the MSU have improved over time with a dedicated team and experience. Methods: We reviewed 100 consecutive patients evaluated on the MSU from July-October 2014 (Group 1), compared to the most recent 100 patients April-July 2017 (Group 2). Collected data including initial NIHSS, patient age, door to CT performance time, door to CT read time, door to needle (DTN) time, alarm to IVT time, MSU scene arrival to departure time, and MSU alarm to back-in-service time were analyzed with rank sum test. Reported times are in medians with interquartile ranges (IQR). Results: Initial median NIHSS (6, IQR 3-12, p=0.78) and ages (65 years old, IQR 55-80, p=0.06) were comparable between the groups. Thrombolysis rate was 16% (n=16) in each cohort. Group 1’s DTN time declined from 31 to 23 minutes (p=0.01). Door to CT completion and read times were faster, at 17 versus 25 minutes (p&lt;0.01), and 10 versus 13 minutes (p&lt;0.01) for Group 2 and Group 1 respectively. MSU arrival to departure time also reduced from 43 to 30 minutes (p&lt;0.01), with total MSU utilization time significantly improved from 88 minutes to 74 minutes (p&lt;0.01) in Group 1 compared to Group 2. While alarm to door times extended from 20 minutes to 22 minutes in Group 2 (p=0.03), the alarm to IVT time was reduced from 55 minutes to 41 minutes (p&lt;0.01). Conclusion: While the MSU geographical range has extended, the alarm to IVT time has shortened, reflecting a learned experience by a specialized team.

The management of one hundred and four cases of STEMI in a cardiology department with no cath lab: Do we respect delays?

ST elevated myocardial infarction (STEMI) is a medical emergency. Moreover, in some developing countries, it is not always easy to access to the transluminal coronary angioplasty (TCA) hence the importance of thrombolysis and respecting delays. This is a retrospective study over 18 months done in our cardiology department enrolling 104 patients hospitalized for STEMI and thrombolysed with tenecteplase after their admission in the cardiac intensive care unit (CICU). We will focus here on the delay of the onset of chest pain to fibrinolysis and first medical contact to fibrinolysis. All the patients were thrombolysed with tenecteplase since we don’t have an easy access to a cath lab. Fifty-three percent of our patients consulted during the night shift. One third of our patients consulted in the first 2 hours and two third in the first 4 hours. 1/Delay of the onset of chest pain to thrombolysis: the average delay between the onset of chest pain to thrombolysis is 4.19 ± 2.7 hours with extremes of 20 minutes and 12 hours. Forty-six percent of our patients were thrombolysed in the first 3 hours, 37.5% were thrombolysed between three and six hours and 16.5% between six and twelve hours. 2/Delay of first medical contact to thrombolysis: all patients were thrombolysed after their admission in the CICU. Ninety-six percent of them were hospitalized and thrombolysed in less than one hour after their first medical contact in the emergency room. Only 2.9% were thrombolysed after the first hour of their first medical contact and only one patient was thrombolysed 4 hours after its admission for uncertain diagnosis. The delay door to needle recommended by the European society of cardiology is 30 minutes; unfortunately, we are out of recommendations. Acute myocardial infarction is a real emergency: “time is myocardium”, that is why we have to encourage the Pre-hospital thrombolysis or at least the thrombolysis in the emergency room to reduce the door to needle delay.

Keys to Achieving Target First Medical Contact to Balloon Times and Bypassing Emergency Department More Important Than Distance.

Background Australian guidelines advocate primary percutaneous coronary intervention (PPCI) as the reperfusion strategy of choice for ST elevation myocardial infarction (STEMI) in patients in whom it can be performed within 90 minutes of first medical contact; otherwise, fibrinolytic therapy is preferred. In a large health district, the reperfusion strategy is often chosen in the prehospital setting. We sought to identify a distance from a PCI centre, which made it unlikely first medical contact to balloon time (FMCTB) of less than 90 minutes could be achieved in the Hunter New England health district and to identify causes of delay in patients who were triaged to a PPCI strategy. Methods and Results We studied 116 patients presenting via the ambulance service with STEMI from January 2016 to December 2016. In patients who were taken directly to the cardiac catheterisation lab, a maximum distance of 50 km from hospital resulted in 75% of patients receiving PCI within 90 minutes and approximately 95% of patients receiving PCI within 120 minutes. Patients who bypassed the emergency department (ED) were significantly more likely to have FMCTB of less than 90 minutes (p < 0.001) despite having a longer travel distance (28.5 km versus 17.4 km, p < 0.001). Patients transiting via the ED were significantly more likely to present out of hours (60 versus 24.2% p < 0.001). Conclusions Patients who do not bypass the ED have a longer FMCTB across all spectrum of distances from the PCI centre; therefore, bypassing the ED is key to achieving target FMCTB times. Using a cutoff distance of 50 km may reduce human error in estimating travel time to our PCI centre and thereby identifying patients who should receive prehospital thrombolysis.

Prehospital care for stroke patients

The effectiveness of thrombolysis or mechanical recanalization for acute stroke is higher, the sooner these therapies are started. Therefore, acute stroke patients need to be evaluated by qualified staff for these therapies as soon as possible. Lay persons need to identify the typical symptoms of stroke as an emergency and act accordingly by calling the emergency medical system (EMS). The EMS team reassesses the symptoms and prompts cerebral imaging. Cerebral imaging is performed ideally in hospitals with a stroke unit where subsequent (stroke) treatments occur. On the way, the emergency team will measure and stabilize vital functions and obtain further important clinical information. Telemedicine allows communicating exact time of onset and severity of symptoms, as well as comorbidities and medication of the patient to the respective hospital. Thereby, the intrahospital workload will be disencumbered and accelerated. Some EMS vehicles now carry point-of-care laboratories and may measure lab values en route (glucose and INR [International Normalized Ratio] for example). Some ambulances are not only equipped with qualified staff, telemedicine technique, and point-of-care labs but even computer tomography (CT) to perform imaging. Such mobile stroke emergency mobiles (STEMO) or mobile stroke units may perform thrombolysis prehospitally. Prehospital thrombolysis has been proven to be initiated faster and is safe. Preliminary results even suggest superiority to intrahospital thrombolysis with respect to clinical outcome. Moreover, STEMO may perform CT-angiography and assess intracranial large-vessel status. If intracranial large-vessel occlusion is present, patients will be brought directly to hospitals able to perform mechanical recanalization. Thus, secondary transports are no longer required.

Pre‐hospital thrombolysis in ST‐segment elevation myocardial infarction: a regional Australian experience

Objective The system of care in the Hunter New England Local Health District for patients with ST-segment elevation myocardial infarction (STEMI) foresees pre-hospital thrombolysis (PHT) administered by paramedics to patients more than 60 minutes from the cardiac catheterisation laboratory (CCL), and primary percutaneous coronary intervention (PCI) at the CCL for others. We assessed the safety and effectiveness of the pre-hospital diagnosis strategy, which allocates patients to PHT or primary PCI according to travel time to the CCL. Design, setting and participants Prospective, non-randomised, consecutive, single-centre case series of STEMI patients diagnosed on the basis of a pre-hospital electrocardiogram (ECG), from August 2008 to August 2013. All patients were treated at the tertiary referral hospital (John Hunter Hospital, Newcastle). Main outcome measures The primary efficacy endpoint was all-cause mortality at 12 months; the primary safety endpoint was bleeding. Results STEMI was diagnosed in 484 patients on the basis of pre-hospital ECG; 150 were administered PHT and 334 underwent primary PCI. The median time from first medical contact (FMC) to PHT was 35 minutes (IQR, 28-43 min) and to balloon inflation 130 minutes (IQR, 100-150 min). In the PHT group, 37 patients (27%) needed rescue PCI (median time, 4 h; IQR, 3-5 h). The 12-month all-cause mortality rate was 7.0% (PHT, 6.7%; PCI, 7.2%). The incidence of major bleeding (TIMI criteria) in the PHT group was 1.3%; no patients in the primary PCI group experienced major bleeding. Conclusion PHT can be delivered safely by paramedical staff in regional and rural Australia with good clinical outcomes.

Spotlight on the April 4 issue

#### Notable in Neurology This issue features an article that reports unilateral cerebellothalamic tract ablation in essential tremor by MRI-guided focused ultrasound, and another that advocates the Narcolepsy Severity Scale as a reliable and valid clinical tool. A featured Contemporary Issues: Innovations in Education article examines a scholarly research program as part of an adult and pediatric neurology residency program. ### Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis![Graphic][1] Mobile stroke treatment units (MSTUs) represent a new frontier in stroke care with the ability to deliver prehospital thrombolysis. The authors' MSTU, with physician presence via telemedicine, demonstrated substantial reductions in … [1]: /embed/inline-graphic-1.gif

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis

To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014-November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Abstract 119: Magnitude of Benefit of Prehospital Mobile Stroke Unit vs Conventional ED Thrombolysis: Preliminary Estimate Based on PHANTOM-S Observational Registry Study

Background: Prehospital thrombolysis in a mobile stroke unit (MSU, CT ambulance) reduces onset to treatment times compared with conventional ED delivery of IV tPA. Studies to determine if MSU thrombolysis improves final functional outcome have been underpowered, but can provide preliminary estimates of benefit magnitude. Methods: We analyzed group outcome data from the PHANTOM-S Observational Registry Study (Kunz et al, 2016). For all possible dichotomizations of the modified Rankin Scale (mRS) of global disability (mRS), net benefit per thousand (BPT) treated patients were derived by multiplying absolute risk differences by 1000 and number needed to treat (NNT) by taking the inverse of absolute risk difference. For benefit in shifting patients to any lower disability level across all 6 functional transitions on the mRS, BPT and NNT were derived using the algorithmic joint outcome table method. Results: Group data were available for 305 patients treated with IV tPA in an MSU and 353 patients treated conventionally in the ED. Of the 6 cutpoints on the mRS, 5 showed more favorable outcomes with MSU care and 1 more favorable outcome with conventional care. The Table shows resulting Benefit per Thousand and NNT values. For the 6 possible dichotomizations of the mRS, the benefit per thousand patients ranged from -21 to 93, with the greatest benefit seen at 0-3, and a BPT of 58 for the study primary outcome of freedom from disability (mRS 0-1). For benefit of improving by 1 or more mRS levels across all 6 transitions of the mRS, the BPT was 182 and NNT 5.5. Conclusions: This preliminary estimate indicates that, out of every 1000 patients treated with prehospital, MSU thrombolysis rather than conventional ED thrombolysis, care, 182 will have a less disabled final outcome, including 58 more who would be free from disability. If confirmed in larger controlled clinical trials, these findings suggest that MSU-based thrombolysis would have a substantial clinical benefit.

Patient care of patients with myocardial infarction in Hungary. Analysis of National Myocardial Infarction Registry data collecting in 2015

comparing the national and international registry data we conclude that we should analyse and decrease the prehospital delay time to improve the patient care in Hungary. Orv. Hetil., 2017, 158(3), 90-93.

Pre-Hospital Thrombolysis in Victoria for Regional STEMI Patients – Reducing Ischaemic Time, Saving Lives and Skilling Paramedics: An Ambulance Victoria Report

Pre-Hospital Thrombolysis in Victoria for Regional STEMI Patients – Reducing Ischaemic Time, Saving Lives and Skilling Paramedics: An Ambulance Victoria Report

New Zealand Paramedics are Ready for An Autonomous Pre-Hospital Thrombolysis Protocol

Introduction Internationally, autonomous paramedic-delivered pre-hospital thrombolysis (PHT) administration for ST-elevation myocardial infarction patients has proven to be a highly effective strategy in facilitating expedited delivery of this treatment modality. However, current New Zealand models rely on physician authorised telemetry-based systems which have proved problematic, particularly due to technological failings. The aim of this study is to establish whether current paramedic education in New Zealand is sufficient for the introduction of an autonomous paramedic clinical decision-making model of PHT. Methods A one-hour workshop introduced a new PHT protocol to 81 self-selected paramedic participants – both rural and metropolitan based – from New Zealand. Paramedics were then tested in protocol application through completion of a scenario-based standardised written test. Four written scenarios constructed from actual field cases assessed 12-lead electrocardiogram interpretation, understanding of protocol inclusion/exclusion criteria, and treatment rationale. Ten multiple-choice questions further tested cardiac and pharmacology knowledge as well as protocol application. Results Overall clinical decision-making showed a sensitivity of 92.0% (95% CI: 84.8–96.5), and a specificity of 95.6% (95% CI: 89.1–98.8). Electrocardiogram misinterpretation was the most common error. University educated paramedics (n=44) were significantly better at clinical decision-making than in-house industry trained paramedics (n=37) (p=0.001), as were advanced life support paramedics (n=36) compared to paramedics of lesser practice levels (n=45) (p=0.006). Conclusion Our New Zealand paramedic sample demonstrated an overall clinical decision-making capacity sufficient to support the introduction of a new autonomous paramedic PHT protocol. Recent changes in paramedic education toward university degree programs are supported.

Rural Inequity in STEMI Treatment Can Be Addressed by Implementation of the New Zealand National STEMI Pathway

Background: Although timely reperfusion therapy is instrumental in determining treatment outcomes for ST-elevation myocardial infarction (STEMI) patients, the lack of a coordinated approach in regional Australasia leads to substantial delays in the delivery of time critical treatment. Methods: A collaborative treatment algorithm involving Emergency Medical Services (EMS) and secondary care aimed to deliver either primary percutaneous coronary intervention (PPCI) or pre-hospital thrombolysis with routine immediate transfer of eligible patients to a PCI centre was developed, trialled and evaluated in the predominantly rural Nelson and Marlborough region of New Zealand. Using data from ANZACS-QI and EMS; parameters including pre-hospital ECG transmission, fibrinolysis administration, device and transfer times were evaluated. Results: Sixty-seven of the 100 consecutive STEMI/presumed STEMI patients from February 2016 onwards met the eligibility criteria; the initial reperfusion strategy included PPCI (n = 36), fibrinolysis (n = 28), and medical treatment (n = 1). First medical contact (FMC) to device time for PPCI patients was 89 minutes (43-194, n = 36, 72.2% < 120 minutes), FMC to pre-hospital needle time was 44 minutes (16-78, n = 28, 23.8% < 30 minutes). FMC to arrival at a PCI centre was 75 minutes (27-278, n = 54, 66% < 90 minutes), however door-in-door-out time (DIDO) time for patients presenting to a non-PCI centre was 99 minutes (25-248, n = 9, 11.10% < 30 minutes). Conclusion: A coordinated STEMI pathway can lead to timely arrival at PCI centres and reperfusion therapy for patients that receive PPCI and reasonable FMC to pre-hospital fibrinolysis. However, poor DIDO from non-PCI centres times require further improvement to achieve equity.

A Favorable Trend but Not A Significant Difference Is Reported in Outcomes for Prehospital Thrombolysis Versus In-Hospital Treatment

A Favorable Trend but Not A Significant Difference Is Reported in Outcomes for Prehospital Thrombolysis Versus In-Hospital Treatment