Thrombolysis in Acute Ischaemic Stroke: A Retrospective Audit of the Role of Alteplase in Hyperacute Stroke Management
DOI:
https://doi.org/10.22317/imj.v9i1.1304Keywords:
Thrombolytic Therapy, Alteplase, Stroke, Ischemic Attack, TransientAbstract
Objectives
This study aimed to investigate the factors contributing to the low thrombolysis rates for acute ischemic stroke at Eastbourne District General Hospital and to formulate evidence-based recommendations to improve timely access to thrombolytic treatment.
Methods
A retrospective audit was conducted on stroke admissions during April–May 2019 and 2020. Patient records were analyzed to assess eligibility for thrombolysis, time of presentation, imaging timelines, and treatment decisions. Comparisons were drawn between in-hours and out-of-hours presentations using descriptive and inferential statistics.
Results
Among 395 suspected stroke cases, 185 thrombolysis alerts were initiated, yet only 21 patients (7.3%) received Alteplase. The majority of these treatments occurred outside of regular hours. Key barriers included delayed door-to-needle times and incomplete pre-alert notifications. Median door-to-needle times frequently exceeded 60 minutes, indicating systemic inefficiencies.
Conclusion
To enhance thrombolysis rates, comprehensive improvements across the stroke care pathway are necessary. These include raising public awareness, streamlining in-hospital procedures, ensuring consistent medical staffing, and exploring the use of faster-acting thrombolytic agents such as Tenecteplase.
References
Bray BD, Cloud GC, James MA, Hemingway H, Wolfe CDA. Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care. Lancet. 2018;392(10164):170–9. https://doi.org/10.1016/S0140-6736(18)31162-9
Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med. 2018;378(17):1573–82. https://doi.org/10.1056/NEJMoa1716405
Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase: a meta-analysis of individual patient data. Lancet. 2014;384(9958):1929–35. https://doi.org/10.1016/S0140-6736(14)60584-5
European Stroke Organisation (ESO) Guidelines Committee. ESO guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021;6(1):I–LXII. https://doi.org/10.1177/2396987321989865
Flynn D, Francis R, Robalino S, et al. Barriers and enablers to delivering intravenous thrombolysis for acute stroke: a systematic review. J Neurol Neurosurg Psychiatry. 2020;91(8):793–801. https://doi.org/10.1136/jnnp-2020-322721
Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: factors associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750–8. https://doi.org/10.1161/CIRCULATIONAHA.110.974675
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–29.
Logallo N, Novotny V, Assmus J, et al. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol. 2017;16(10):781–8. https://doi.org/10.1016/S1474-4422(17)30253-3
Meretoja A, Strbian D, Mustanoja S, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology. 2012;79(4):306–13. https://doi.org/10.1212/WNL.0b013e31825d6011
Menon BK, Buck BH, Singh N, et al. Intravenous tenecteplase compared with alteplase for acute ischemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. Lancet. 2022;400(10347):161–9. https://doi.org/10.1016/S0140-6736(22)00891-1
NHS England. The NHS Long Term Plan. 2019. Available from: https://www.longtermplan.nhs.uk/
National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–e418. https://doi.org/10.1161/STR.0000000000000211
Rudd AG, Hoffman A, Grant R, et al. SSNAP Annual Report: Stroke Care in England, Wales and Northern Ireland 2021–22. Royal College of Physicians; 2022.
Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309(23):2480–8.
SSNAP Collaboration. Sentinel Stroke National Audit Programme (SSNAP) Annual Report 2022. Healthcare Quality Improvement Partnership (HQIP); 2023. Available from: https://www.strokeaudit.org/SupportFiles/Documents/Patient/SSNAP-PLS-Annual-Report-2023.aspx
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