Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility

Background: Thrombolytic therapy for acute stroke (<3 hours) will not have a major impact on death and dependency unless it is accessible to more pati ents, Objective: To determine why patients with ischemic stroke did not rec eive TV TPA and assess the availability of this therapy to patients with is chemic stroke. Methods: Consecutive patients with acute ischemic stroke wer e prospectively identified at a university teaching hospital between Octobe r 1996 and December 1999. Additional patients with ischemic stroke were ide ntified that were admitted to one of three other hospitals in the Calgary r egion during the study period. The Oxford Community Stroke Programme Classi fication was used to record type and side of stroke. Results: Of 2165 strok e patients presenting to the university hospital, 1168 (53.9%) were diagnos ed with ischemic stroke, 31.8% with intracranial hemorrhage (intracerebral, subarachnaid, or subdural), and 13.9% with TIA. Delay in presentation to e mergency department beyond 3 hours excluded 73.1% (854/1168). Major reasons for delay included uncertain time of onset (24.2%). patients waited to see if symptoms would improve (29%), delay caused by transfer fr om an outlyin g hospital (8.9%), and inaccessibility of treating hospital (5.7%). Twenty- seven percent of patients with ischemic stroke (314/1168) were admitted wit hin 3 hours of symptom onset and of these 84 (26.7%) patients received IV T PA. The major reasons for exclusion in this group of patients (<3 hours) we re mild stroke (13.1%), clinical improvement (18.2%), perceived protocol ex clusions (13.6%), emergency department referral delay (8.9%), and significa nt comorbidity (8.3%). Of those patients who were considered too mild or we re documented to have had significant improvement, 32% either remained depe ndent at hospital discharge or died during hospital admission. Throughout t he region there was a total of 1806 ischemic stroke patients (admitted to a ll four Calgary hospitals). During this study period, 4.7% received IV TPA. Conclusions: The majority of patients are unable to receive TPA for acute ischemic stroke because they do no not reach the hospital soon enough. Of t hose patients presenting within 3 hours, 27% received the therapy but a fur ther 31% were excluded because their symptoms were either considered too mi ld or were rapidly improving. Subsequently, a third of these patients were left either dependent or dead, bringing into question the initial decision not to treat.