Eligibility Assessment for Intravenous Thrombolytic Therapy in Acute Ischemic Stroke Patients; Evaluating Barriers for Implementation

BACKGROUND: Intravenous thrombolysis is an approved treatment method for patients with acute ischemic stroke (AIS) and is recommended by multiple guidelines. However, it seems that it is less frequently used in the developing countries compared to the developed countries. OBJECTIVES: The purpose of this study was to estimate the percentage of patients with AIS, eligible for intravenous thrombolytic therapy, at the main referral center in Northwest Iran and to determine the main barriers for implementation of this method. PATIENTS AND METHODS: Over one year, 647 patients who were admitted to the emergency department and met the Cincinnati Stroke Scale were enrolled into the study. The center to which patients were admitted, is a tertiary university hospital that has the required infrastructure for thrombolytic therapy in AIS. Factors recorded were neurological examinations and time between onset of symptoms and hospital arrival, hospital arrival and performance of brain computed tomography (CT) scanning, and hospital arrival to complete the investigations. Patients eligible for intravenous thrombolytic therapy were identified according to the American Heart Association (AHA) guidelines. RESULTS: Mean time interval between hospital arrival and completion of brain CT scanning was 91 minutes (range: 20–378 minutes) and mean time from hospital arrival to completion of investigations was 150 minutes (range: 30–540 minutes). A total of 159 (31.3%) patients arrived at hospital within 3 hours of the onset of symptoms (early enough for intravenous thrombolytic therapy). However, 81.7% (130/159) of these patients missed thrombolytic therapy due to delayed performance of brain CT scanning and laboratory tests and 38.3% (61/159) had contraindications. The remaining 16 patients (10% of those who arrived within 3 hours and 3.1% of all cases) were eligible for thrombolytic therapy. CONCLUSIONS: The major barriers for thrombolytic therapy for patients with AIS in this setting were delays in the provision of in-hospital services, like initial patient assessment, CT scans or laboratory studies. These results were in contrast with previous reports.