Skip to main content

Reasons for low thrombolysis rate in a Norwegian ischemic stroke population

Abstract

Only a minor proportion of patients with acute ischemic stroke receive treatment with intravenous thrombolysis. The purpose of this study was to explore reasons for not giving thrombolysis and to determine if there was a correlation between prehospital and in-hospital delay in a Norwegian ischemic stroke population. Patients with acute ischemic stroke were included during a 1-year period. Time intervals for prehospital and in-hospital delay, reasons for not treating with thrombolytic therapy in patients admitted within the time window and reasons for late arrival were recorded. In all, 290 patients were included, and 7.6 % were treated with intravenous thrombolysis. The most frequent reasons for not treating eligible patients were: minor symptoms (22.8 %), clinical improvement (17.5 %) and uncertainty about the diagnosis (12.3 %). Patients’ reasons for delayed admission were: not attributing their symptoms to stroke (25.4 %), a wait-and-see attitude (25.4 %), and choosing to wait for the GP’s office to open (14.3 %). Prehospital delay was strongly correlated to in-hospital delay (p < 0.001). In conclusion, a large percentage of patients with AIS are not treated with thrombolysis because of mild or rapidly improving symptoms, and because patients arrive too late to the hospital. Absolute and relative contraindications account for a minor proportion of reasons for excluding patients.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329

    CAS  PubMed  Article  Google Scholar 

  2. Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375:1695–1703

    CAS  PubMed  Article  Google Scholar 

  3. Hacke W, Donnan G, Fieschi C, Kaste M, Von KR, Broderick JP et al (2004) Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 363:768–774

    PubMed  Article  Google Scholar 

  4. Reeves MJ, Arora S, Broderick JP, Frankel M, Heinrich JP, Hickenbottom S et al (2005) Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke 36:1232–1240

    PubMed  Article  Google Scholar 

  5. Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM (2001) Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 56:1015–1020

    CAS  PubMed  Article  Google Scholar 

  6. Tong D, Reeves MJ, Hernandez AF, Zhao X, Olson DM, Fonarow GC et al (2012) Times from symptom onset to hospital arrival in the Get With The Guidelines-Stroke Program 2002 to 2009: temporal trends and implications. Stroke 43:1912–1917

    PubMed  Article  Google Scholar 

  7. Bouckaert M, Lemmens R, Thijs V (2009) Reducing prehospital delay in acute stroke. Nat Rev Neurol 5:477–483

    PubMed  Article  Google Scholar 

  8. Saver JL, Smith EE, Fonarow GC, Reeves MJ, Zhao X, Olson DM et al (2010) The “golden hour” and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset. Stroke 41:1431–1439

    PubMed Central  PubMed  Article  Google Scholar 

  9. Evenson KR, Foraker RE, Morris DL, Rosamond WD (2009) A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke 4:187–199

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  10. Faiz KW, Sundseth A, Thommessen B, Rønning OM (2013) Prehospital delay in acute stroke and TIA. Emerg Med J 30:669–674

    PubMed  Article  Google Scholar 

  11. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J et al (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870

    CAS  PubMed  Article  Google Scholar 

  12. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41

    PubMed  Article  Google Scholar 

  13. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:1521–1526

    CAS  PubMed  Article  Google Scholar 

  14. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee (2008) Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 25:457–507

    Article  Google Scholar 

  15. Nedeltchev K, Schwegler B, Haefeli T, Brekenfeld C, Gralla J, Fischer U et al (2007) Outcome of stroke with mild or rapidly improving symptoms. Stroke 38:2531–2535

    PubMed  Article  Google Scholar 

  16. Smith EE, Fonarow GC, Reeves MJ, Cox M, Olson DM, Hernandez AF et al (2011) Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke. Stroke 42:3110–3115

    CAS  PubMed  Article  Google Scholar 

  17. Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH (2005) Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke 36:2497–2499

    CAS  PubMed  Article  Google Scholar 

  18. Willey JZ, Stillman J, Rivolta JA, Vieira J, Doyle MM, Linares G et al (2012) Too good to treat? Outcomes in patients not receiving thrombolysis due to mild deficits or rapidly improving symptoms. Int J Stroke 7:202–206

    PubMed Central  PubMed  Google Scholar 

  19. Baumann CR, Baumgartner RW, Gandjour J, von Budingen HC, Siegel AM, Georgiadis D (2006) Good outcomes in ischemic stroke patients treated with intravenous thrombolysis despite regressing neurological symptoms. Stroke 37:1332–1333

    PubMed  Article  Google Scholar 

  20. Kohrmann M, Nowe T, Huttner HB, Engelhorn T, Struffert T, Kollmar R et al (2009) Safety and outcome after thrombolysis in stroke patients with mild symptoms. Cerebrovasc Dis 27:160–166

    CAS  PubMed  Article  Google Scholar 

  21. Chernyshev OY, Martin-Schild S, Albright KC, Barreto A, Misra V, Acosta I et al (2010) Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 74:1340–1345

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  22. Lecouturier J, Rodgers H, Murtagh MJ, White M, Ford GA, Thomson RG (2010) Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment. BMC Public Health 10:784

    PubMed Central  PubMed  Article  Google Scholar 

  23. Alberts MJ (2012) Improving public education about stroke. Ann N Y Acad Sci 1268:45–50

    PubMed  Article  Google Scholar 

  24. Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV, Pan W et al (2013) Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 309:2480–2488

    CAS  PubMed  Article  Google Scholar 

  25. Kleindorfer DO, Broderick JP, Khoury J, Flaherty ML, Woo D, Alwell K et al (2007) Emergency department arrival times after acute ischemic stroke during the 1990s. Neurocrit Care 7:31–35

    PubMed  Article  Google Scholar 

  26. Addo J, Ayis S, Leon J, Rudd AG, McKevitt C, Wolfe CD (2012) Delay in presentation after an acute stroke in a multiethnic population in South London: the South London Stroke Register. J Am Heart Assoc 1:e001685

    PubMed Central  PubMed  Article  Google Scholar 

  27. Agyeman O, Nedeltchev K, Arnold M, Fischer U, Remonda L, Isenegger J et al (2006) Time to admission in acute ischemic stroke and transient ischemic attack. Stroke 37:963–966

    PubMed  Article  Google Scholar 

  28. Jungehulsing GJ, Rossnagel K, Nolte CH, Muller-Nordhorn J, Roll S, Klein M et al (2006) Emergency department delays in acute stroke–analysis of time between ED arrival and imaging. Eur J Neurol 13:225–232

    CAS  PubMed  Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kashif Waqar Faiz.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Faiz, K.W., Sundseth, A., Thommessen, B. et al. Reasons for low thrombolysis rate in a Norwegian ischemic stroke population. Neurol Sci 35, 1977–1982 (2014). https://doi.org/10.1007/s10072-014-1876-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10072-014-1876-4

Keywords

  • Ischemic stroke
  • Thrombolysis
  • Prehospital delay
  • In-hospital delay
  • Recombinant tissue plasminogen activator
  • Minor symptoms