Gaps and barriers

Thrombolysis in stroke remains underutilised in daily practice

  • Several studies have shown that intravenous rt-PA is applied in <3% of patients with stroke, although up to 25% of acute ischaemic stroke patients might be eligible for thrombolysis.1
  • The main obstacles to delivery of thrombolysis are:
    • Lack of experience and fear of complications
    • Lack of public awareness
    • Poor infrastructure
    • Non-availability of rt-PA at the hospital
    • Delays beyond the time of eligibility for rt-PA (pre-hospital and in-hospital)
  • Improvement of pre- and in-hospital procedures can increase the number of patients who receive rt-PA.2
  • Elements of the stroke care system (e. g., acute care, inpatient rehabilitation, community care) are often still very demarcated in terms of definition, purpose, and accountability3
    • Stroke-related care becomes fragmented caused by inadequate integration of the various facilities, agencies, and professionals that should closely collaborate in providing stroke care.4

The emergency physician’s perspective

Poor patient education:

  • Almost 40% of patients admitted with a possible stroke did not know the signs, symptoms, or risk factors of a stroke.6
  • Patients did not call the right number: 42% contacted their general practitioner (GP) instead of the emergency medical services, if a stroke was suspected.7

Studies have shown low thrombolysis rates for hospitals with no specific organisation or stroke protocol in place (18.2%) (OR=5.43, 95% CI: 3.84-7.73) and for those with an in-hospital restricted stroke code (37.9%) (OR=1.97, 95% CI: 1.53-2.54) compared with hospitals with a pre-notification system (54.7%).8

Studies have also shown that before the implementation of stroke protocols, the proportion of patients with an acute ischaemic stroke who received rt-PA was very low.9

The neurologist’s perspective

  • Not all stroke patients have access to optimal care in practice, often because of a lack or specialist stroke facilities10
    • Only 11.4% of 448 hospitals provided facilities that met the Stroke Unit Criteria assessed by the ESO in 2007.
    • In two thirds of cases that receive rt-PA, the door-to-needle time is >60 min.
    • Stroke expertise is mandatory to recognise stroke mimics, but experts are not always close-by.
References 
  1. Etgen T, et al. Multimodal strategy in the successful implementation of a stroke unit in a community hospital. Acta Neurol Scand 2011;123:390-395.
  2. Roos YB, et al. The acute brain care unit (abc-unit) – the initiation of a multidisciplinary treatment protocol and special unit for iv thrombolysis in stroke reduces the median door-to-needle time to 26 minutes (Abstract). Cerebrovasc Dis 2011;31:33.
  3. Cameron JI, Tsoi C, Marsella A. Optimizing stroke systems of care by enhancing transitions across care environments. Stroke 2008;39:2637-2643.
  4. Schwamm LH, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Stroke 2005;36:690-703.
  5. Lambert Y. Presentation at the ESC in Hamburg, 2011.
  6. Kothari R, et al. Patients' awareness of stroke signs, symptoms, and risk factors. Stroke 1997;28:1871-1875.
  7. Jones SP, Jenkinson AJ, Leathley MJ, Watkins CL. Stroke knowledge and awareness: an integrative review of the evidence. Age Ageing 2010;39:11-22.
  8. Dalloz MA, et al. Thrombolysis rate and impact of a stroke code: A French hospital experience and a systematic review. J Neurol Sci 2011;[Epub ahead of print]
  9. Audebert H. Presentation at the ESC in Hamburg, 2011.
  10. Leys D, Ringelstein EB, Kaste M, et al. Facilities available in European hospitals treating stroke patients. Stroke 2007;38:2985-2891.