Prioritizing interventions to improve rates of thrombolysis for ischemic stroke

Background: Thrombolytic treatment has been shown to be effective in the treatment of ischemic stroke when initiated within 3 hours of symptom onset, yet few patients receive thrombolytics. Objective: To estimate expected increases in use of thrombolytics for ischemic stroke given the following interventions: educating patients to present earlier, optimizing Emergency Medical Services (EMS) response/transport times, optimizing hospital systems, and extending the treatment window. Methods: As part of a Centers for Disease Control-sponsored Coverdell Acute Stroke Pilot Registry, the authors prospectively identified all patients with an initial diagnosis of ischemic stroke at 11 hospitals in California over a 3-month period. Timing of symptom onset, EMS response, hospital arrival, treatment, and reasons for nontreatment were evaluated, and hypothetical treatment rates for thrombolysis for interventions on the stroke-care continuum were derived based on observed rates of eligibility and treatment. Results: Of 374 patients with ischemic stroke, 88 (23.5%) arrived at the emergency department within 3 hours of symptom onset, of whom 16 (4.3%) received thrombolysis. If all patients with known onset times had called 911 immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased from 4.3 to 28.6%. Expected rates of thrombolysis were lower for other interventions: instantaneous prehospital response 5.5%, perfect hospital care 11.5%, and extension of time window to 6 hours 8.3%. If all patients with known onset had arrived within 1 hour and been optimally treated, 57% could have been treated. Conclusion: Campaigns that educate patients to seek treatment sooner should be major components of system-wide interventions to increase rates of thrombolysis for acute ischemic stroke.