Time Barriers to Receiving Recombinant Tissue Plasminogen Activator in Patients with Acute Ischemic Stroke
Keywords:Acute ischemic stroke, tissue plasminogen activator, rtPA, timeline
Objective: This study aimed to evaluate the barriers and limitations of receiving recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke.
Methods: The present study is a cross-sectional study that was performed on 188 patients with ischemic stroke who were referred for rtPA treatment. Patient records were quarried for demographic information and timelines of events from onset of symptoms and Emergency Department referral to rtPA treatment invitation. Patients were divided into groups of rtPA receiving group and the non-rtPA group. Collected data were analyzed by SPSS 20 software.
Results: The mean age of patients was 67.28±12.55 years. Meantime to emergency physician visit (P=0.2), the average time to neurologist visit (P = 0.3), the average time to CT scan (P=0.08), and average time to CT scan interpretation (P = 0.4) had no statistically significant difference between the rtPA receiving group and the non- rtPA group. But the average time from the onset of symptoms to reaching the emergency room (P = 0.001), the average time until the patient was assigned to a neurologist (P = 0.05), the average time from the emergency physician visit to the first instruction by the nurse (P = 0.02), the average time to blood test preparation (P = 0.001) and mean NIHSS score (P = 0.005) in the rtPA group were significantly lower than the non-rtPA group.
Conclusion: According to the findings, delay in referring patients to medical centers is the most important obstacle to not receiving rtPA. There are also several inhibitory factors from the time of entering the emergency room to receiving rtPA, but all of these factors can be intervened based on further researches.
Ethics approval and consent to participate:
The study was approved by the Institutional Review Board of Mashhad University of Medical Sciences.
Consent For Publication:
Availability of Data and Materials:
All data are available in the article.
Mashhad University of Medical Sciences.
MF and RG designed the study. EP and RG quarried patient records for assessing timelines. The manuscript was written by EP and RG and revised by MF.
The authors are grateful for the cooperation of Ghaem Hospital, affiliated with the Vice Chancellor for Research of Mashhad University of Medical Sciences.
1. Deguchi K, Miyazaki K, Tian F, Liu N, Liu W, Kawai H, et al. Modifying neurorepair and neuroregenerative factors with tPA and edaravone after transient middle cerebral artery occlusion in rat brain. Brain Res 2012; 1436: 168-77.
2. Broderick J, Brott T, Kothari R, Miller R, Khoury J, Pancioli A, et al. The Greater Cincinnati/Northern Kentucky Stroke Study Preliminary first-ever and total incidence rates of stroke among blacks. Stroke. 1998;29(2):415-21.
3. Xue G. [Epidemiology of stroke in urbans and rural areas of China: an analysis of stroke mortality rates in 1986]. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi. 1991;12(6):357-62.
4. Forbes J. Cost of stroke. Scottish medical journal. 1993;38(3 Suppl):S4.
5. Kasmaei HD, Baratloo A, Nasiri Z, Soleymani M, Yazdani MO. Recombinant tissue plasminogen activator administration in patients with cerebrovascular accident; a case series. Archives of Neuroscience. 2015;2(2).
6. Kim JS. Stroke in Asia: A global disaster. Int J Stroke 2014; 9(7): 856-7.
7. Zhang W, Sato K, Hayashi T, Omori N, Nagano L, Horiuchi S, et al. Extension of ischemic therapeutic time window by a free radical scavenger, Edaravone, reperfused with tPA in rat brain. Neurol Res 2004; 26(3): 342-8.
8. Noor R, Wang XC, Shuaib A, Hyperthermia masks the neuroprotective effetcs of tissue plasminogen activator, Stroke 2005; 36(3): 665-9.
9. Aldandashi S, Noor R, Wang CX, Uddin G, Shuaib A. Combination treatment with dipyridamole, aspirin, and tPA in an embolic model of stroke in rats. Experimental neurology. 2007;205(2):563-8.
10. Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, et al. Cost-effectiveness of recombinant tissue-type plasminogen activator within 3 hours of acute ischemic stroke: current evidence. Stroke. 2014;45(10):3032-9.
11. Mojdehipanah H, Yazdi Z, Nasiri M, Azizlo Z. Barriers to delivery of tissue plasminogen activator for patients with acute ischemic stroke. Feyz Journal of Kashan University of Medical Sciences. 2015;19.
12. Putaala J, Yesilot N, Waje-Andreassen U, Pit-käniemi, Vassilopoulou S, Nardi K, et al. Demographic and Geographic Vascular Risk Factor Differences in European Young Adults with Ischemic Stroke: The 15 Cities Young Stroke Study. Stroke. 2012;43:2624-30.
13. Greenberg D, Aminof M, Simon R. Clinical neurology. 8th ed. New York: McGraw Hill, 2012.
14. Farghaly W, El-Tallawy N, Shehata Gh, Rageh T, Abdel-Hakeem N, Abd Elhamed M, et al. Epidemiology of nonfatal stroke and transient ischemic attack in Al-Kharga District, New Valley, Egypt. Neuropsychiatr Dis Treat 2013; 9: 1785-90.
15. Appelros P, Stegmayr B, Terent A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009;40:1082–1090.
16. Stegmayr B, Asplund K, Kuulasmaa K, Rajakangas AM, Thorvaldsen P, Tuomilehto J. Stroke incidence and mortality correlated to stroke risk factors in the WHO MONICA Project. An ecological study of 18 populations.
17. Feigin VL, Lawes CM, Bennett DA, BarkerCollo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population based studies: a systematic review. Lancet Neurol. 2009;8: 355-369.
18. Katzan IL, Furlan Aj, Lloyd Le, Frank JI, Harper DL, Hinchey Ja, et al. Use of Tissu TypePlasminogen Activator for Acute Ischemic Stroke: the Cleveland area experience. JAMA 2000; 283(9): 1151-8.
19. Bambauer KZ, Johnston SC, Bambauer DE, Zivin JA. Reasons Why Few Patients with Acute Stroke Receive Tissue Plasminogen Activator. Arch Neurol 2006; 63(5): 661-4.
20. Hatamabadi HR, Mansourifar H, Asarzadegan F, Shojaee M. Barriers to On Time Delivery of Thrombolytic Therapy for Patients with Acute Stroke. J Mazand Univ Med Sci 2013; 23(103): 107-10.
21. Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau MV, Pan W, et al. Time to Treatment With Intravenous Tissue Plasminogen Activatorand Outcome From Acute Ischemic Stroke. JAMA 2013; 309(23): 2480-8.
22. Grotta JC, Burgin WC, El-Mitwalli A, Long M, Campbell M, Morgenstern LB, et al. Intravenous Tissue-Type Plasminogen Activator Therapy for Ischemic Stroke: Houston experience 1996-2000. Arch Neurol 2001; 58(12): 2009-13.
23. Gurav SK, Zirpe KG, Wadia R, Pathak MK, Deshmukh AM, Sonawane RV, et al. Problems and limitations in thrombolysis of acute stroke patients at a tertiary care center. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2015;19(5):265.
24. Adam Kobayashi, Marta S, Tomasz L, Anna C. Lack of experience of intravenous thrombolysis for acute ischemic stroke does not influence the proportion of patients treated. Emerg Med J. 2007;24:96–99.
25. Sushma K, Kapil G, Wadia RS, Avinash N, Prajakta U, Amit T, et al. Impact of “Stroke Code”-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke. Indian J Crit Care Med. 2018 Apr; 22(4): 243–248.
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