Introduction:
Intravenous tissue plasminogen activator (IV tPA) has been approved for treating strokes up to 3 hours after onset of symptoms and may be beneficial up to 4.5 hours in patients who qualify. Additionally, neuro-intervention, i.e., intra-arterial thrombolysis or thrombectomy, is also an approved treatment option. Population studies show that 6% receive IV tPA within 3 hours of stroke onset. However, in-hospital strokes present challenges to treating within an adequate time. We present here our experience with in-hospital strokes, treatments, and identifiable delays in treatments.
Methods:
Single, tertiary center retrospective study of 55 in-hospital strokes over a one-year period from January 2009 to January 2010, and strokes in the Emergency Department over 6 month period from January 2010 to June 2010.
Results:
Twenty-nine in-hospital strokes were evaluated within 3 hours of symptoms onset. Two (6.9%) received IV tPA, and four (13.8%) received neuro-intervention (either intra-arterial thrombolysis or thrombectomy). None of the patients who presented greater than 3 hours after symptom onset was treated with any treatment (n=28). When compared to patients who present to the ED within 3 hours, in-hospital strokes were less likely to get IV tPA (6.9% vs. 20.8%), and they were more likely to receive neuro-intervention (13.8% vs. 10.3%). Neuro-intervention was performed on 9.09% of all in-hospital strokes (1 of 5 presented beyond the 3 hour time window). For in-hospital strokes that receive any treatment within 3 hours, the average time to neurology evaluation, to CT, and to treatment are 35 min, 68 min, and 237 min, respectively. For strokes in the Ed, the average time to evaluation, to CT, and to treatment are 90 min, 28 min, and 66 min respectively. The delay for in-hospital strokes is in obtaining the CT and initiating the treatment.
Discussion:
In-hospital stroke patients wait longer than their ED counterparts to be taken to CT and to receive stroke treatment. They are also less likely to receive IV tPA, and more likely to receive neuro-intervention. The longer time to neuro-imaging and thrombolytic treatment may reflect the fact that patients suffering in-hospital strokes have more complex medical co-morbidities that must be taken account during the evaluation and administration of thrombolytic therapy.
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