Barriers to Thrombolysis at A Tertiary Care Public Hospital- A Prospective Observational Study from Southern Part of India

Background: Intravenous thrombolysis (IVT) is an effective treatment for carefully selected acute ischemic stroke (AIS) patients. However, very few eligible candidates access it in time around the world, including India, due to multiple barriers. Objective: We explored the barriers to IVT in patients of AIS presenting within a 4.5-h window period in our hospital. Materials and Methods: This was a prospective study of AIS patients presenting in <4.5 h of symptom-onset, aged >18 years at the Neuro-casualty, Department of Neurology, from May 2016 to November 2017. Assessment of barriers to intravenous thrombolysis was done, and an attempt to delineate the reasons for the pre-hospital and the in-hospital delay was made. Results: A total of 103 (M:F: 67:36) patients aged between 18 and 80 years, were recruited, with 28 (27.2%) patients aged <45 years. Among them, 29 (28.2%) were thrombolysed. The major reasons for the pre-hospital delay were ignorance about the need for stroke center consultation- 94 (90.3%), consultation elsewhere before the presentation- 84 (81.5%), and non-availability of an ambulance at referring hospitals- 50 (59.52% out of 84). Sixty-four patients (62.1%) could not name any symptoms of stroke, 84 (83.5%) could not name any risk factor, and only 4 (3.9%) were aware of IVT. Key in-hospital barriers were crowded emergency- 80 (77.7%), financial constraints- 79 (76.7%), and delay in CT scan- 62 (61.4%). Delay in arriving at a consensus for IVT by the patient/relative and the treating neurologist, was noted in 24 (43.6%) of the 55 eligible. Conclusion: Many eligible patients remain deprived of thrombolysis due to lack of awareness, financial constraints, and organizational elements, which should be addressed to improve IVT rates.