The finding that few patients with acute ischemic stroke arrive at the hospital soon enough for thrombolytic therapy to be considered should remind physicians to warn patients at risk for stroke of the possible symptoms and the importance of immediate presentation to an emergency department, according to an article in the March issue of the Archives of Neurology.

In the current study, American researchers probed how many patients with an ischemic stroke in progress arrive at an appropriate emergency department in time for use of intravenous tissue plasminogen activator (tPA) to be considered. Current guidelines recommend that drug therapy be initiated within 3 hours of symptom onset. National estimates had suggested that thrombolytic therapy is used in only about 2 percent of eligible patients.

Irene L. Katzan, M.D., M.S., and her colleagues reviewed the records of patients admitted for stroke to the nine centers of a major urban healthcare system from June 15, 1999 to June 15, 2000. There were 1,923 admissions for ischemic stroke during the year; of these, 288 (15 percent) presented within the 3-hour time window, and approximately 6.9 percent were considered eligible for intravenous therapy. The most common reasons patients were ineligible for therapy with tissue plasminogen activator even if they arrived within the appropriate time window were mild neurologic impairment or rapidly improving symptoms. Overall, the researchers found that the rate of use of thrombolytic therapy among patients who arrived at the hospital within the eligible period was 19.4 percent, with rate of use among eligible patients 43.4 percent.

"Delay to Emergency Department (ED) presentation was the primary reason that patients with acute stroke did not receive IV tPA in our nine-hospital system in northeastern Ohio; only 15 percent of patients with stroke arrived within 3 hours of symptom onset," wrote the authors. "The percentage of patients with stroke arriving at the ED within 3 hours varies widely in published studies, ranging from 18 percent in a series of academic centers to 46 percent in a community system. However, even the highest rates are suboptimal, and shortening ED arrival times will have the single greatest impact on increasing IV tPA use in the United States."