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Current situation

Thrombolysis in stroke remains underutilised in daily practice

  • Across the globe, fewer than 5% of patients with acute ischaemic stroke receive intravenous thrombolysis within the eligible therapeutic time window, despite that up to 25-33 % of patients with acute ischaemic stroke 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
    • Hospital does not have thrombolytics
    • Delays beyond the time of eligibility for thrombolytics (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 demarcated in terms of definition, purpose, and accountability.3
    • Stroke-related care may be fragmented because of inadequate integration of the various facilities, agencies, and professionals that should closely collaborate in providing stroke care.4 
    • However, major advances have occurred in the management of acute stroke within the last decade, and new technologies, such as telemedicine and mobile stroke units, have reduced the fragmentation of care in some areas, allowing stroke experts to be available wherever the patient is located.5

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 thrombolytics 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

  • Across Europe, it is estimated that only about 30% of stroke patients receive stroke unit care.11

    • Significant differences can be found between European countries in the number of stroke units and percentage of patients treated in stroke units, ranging from <10% in Malta, Iceland, Romania, and Ukraine to >85% in Sweden and Norway.12
  • In two thirds of cases that receive thrombolytics, the door-to-needle time is >60 min.13
  • Stroke expertise is mandatory to recognize stroke mimics, but experts are not always close-by.
References

  1. Saini V, Guada L, Yavagal DR. Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions. Neurology 2021;97(20 Suppl 2):S6-S16.

  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;31:3.

  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. Adeoye O, et al. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke 2019;50(7):e187-e210.

  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 2012;314(1-2):120-125. 

  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.

  11. Mikulik, R., V. Caso, and N. Wahlgren. Past and Future of Stroke Care in Europe. ORUEN – The CNS Journal 2017;19-26.

  12. Budincevic H, et al. CEESS Working Group. Management of ischemic stroke in Central and Eastern Europe. Int J Stroke. 2015;10 Suppl A100:125-127.

  13. Fonarow GC, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation 2011;123(7):750-8.

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