Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke

J Stroke Cerebrovasc Dis. 2019 Dec;28(12):104329. doi: 10.1016/j.jstrokecerebrovasdis.2019.104329. Epub 2019 Oct 10.

Abstract

Background and purpose: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes.

Methods: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented.

Results: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes.

Conclusions: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.

Keywords: Ischemic stroke; door-to-needle; stroke outcomes; thrombolysis; tissue plasminogen activator.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Brain Ischemia / diagnosis
  • Brain Ischemia / drug therapy*
  • Brain Ischemia / physiopathology
  • Cerebral Hemorrhage / chemically induced
  • Disability Evaluation
  • Drug Administration Schedule
  • Emergency Service, Hospital
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Male
  • Middle Aged
  • Recovery of Function
  • Retrospective Studies
  • Risk Factors
  • Stroke / diagnosis
  • Stroke / drug therapy*
  • Stroke / physiopathology
  • Thrombolytic Therapy* / adverse effects
  • Time Factors
  • Time-to-Treatment*
  • Tissue Plasminogen Activator / administration & dosage*
  • Tissue Plasminogen Activator / adverse effects
  • Treatment Outcome

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator