We have already blogged about acute stroke, thrombolytic therapy with t-PA, and the importance of getting to the hospital right away for early treatment.
However, even now that t-PA can be administered to most stroke patients within 4.5hrs since the onset of their symptoms, only around 5% of acute stroke patients receive the clot busting drug in the USA, more (7-8%) at certified stroke centers.
The #1 reason for not receiving t-PA is missing the time window for safe administration.
The drug must be administered within 4.5hrs (or 3hrs for some patients) since the onset of stroke symptoms in order for the benefits of the drug to exceed the risk.
Why don’t stroke patients get to the hospital in time?
Uncertain time of stroke onset.
In many cases, stroke happens during sleep, patients go to bed normal and wake up many hours later with a stroke.
We don’t know exactly what time the stroke occurred, and we have to go by the time when they were last known to be normal, which often put them outside that 3-4.5hr window.
Lack of knowledge.
However, there are still many patients who could get to the hospital in time to receive t-PA but don’t.
This is a failure of public education.
Studies have shown that as many as 1/3 of people surveyed cannot name a single symptom of stroke, and that 1/10 of people surveyed are not aware there is a time sensitive treatment available.
Only 2/3 stoke patients choose to call 911 and come to the hospital by ambulance – those that do are 50% more likely to get t-PA.
This is the reason for the ad campaigns like the AHA’s “act FAST” and “Time is brain”.
Even if they do get to the ED in time, most stroke patients still don’t get t-PA
Only 1/3 of acute stroke patients who do get to the hospital in time get t-PA!
Many have a definite contraindication, like taking blood thinners or having had recent major surgery, that does make the treatment too risky. These are a subset of stroke patients who should be considered for interventional procedures to directly retrieve blood clot from the cerebral arteries at comprehensive stroke centers.
However, as many as a 1/3 of acute stroke patients seen within that 3-4.5hr time window do not receive t-PA because their neurologic deficit is considered to be “too mild or rapidly reversing”. Obviously, this is a statement that is so hard to define, and yet still considered by many physicians to be contraindication to the use of the drug.
Many of us would argue that to the patient, there is no such thing as a “mild” stroke.
Some affected patients just get a quick screening examination lying on a gurney, and are quickly dismissed as having had “mild stroke” even though they can’t stand and walk because this was never tested.
Our own research from our certified stroke center at Monmouth Medical Center has corroborated these concerns:
We reviewed the charts from all acute stroke patients seen at Monmouth Medical Center from 2008-2012:
8% got t-PA.
75% were excluded because came outside the 3-4.5hr time frame for administration of t-PA.
9% were seen in time for t-PA, but either refused treatment or couldn’t get it because if a definite contra-indication.
8% did not get t-PA because of a “mild or rapidly improving deficit” – of those, 13% needed rehab placement, so there deficit wasn’t so mild after all!
Obviously, our goal is to give more t-PA to stroke patients who can benefit from the clot busting treatment.
We are working hard on public education events to get stroke patients to come to ED sooner, and we are also going to be treating more patients with “mild” deficits as long as they meet eligibility criteria.
What can you do?
Know the warning signs of stroke.
If you, or anyone you know, shows any of these signs call 911 and get them to the hospital right away.
Be a participant in your own or your loved one’s medical decision making – if there seems to be any residual stroke symptoms (however mild) ask about t-PA treatment for stroke.