Eligibility for Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke

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Abstract
The eligibility for recombinant tissue plasminogen activator (rtPA) is rare. We analyze the reasons for exclusion from rtPA among patients who were admitted to our hospital within 3 h. A strict protocol for hyperacute stroke was set in a university teaching hospital. Consecutive patients activating the protocol from June 2004 to October 2005 were prospectively registered and entered into a computerized database. The patients were excluded from rtPA according to the modified exclusion criteria from the National Institute of Neurological Disorders and Stroke rtPA trial. Of the 182 patients activating the protocol, only 11 (6.04%) received intravenous rtPA and 4 (2.2%) IA thrombolysis. Patients were excluded for multiple reasons, and the main reasons for exclusion were minor or improving stroke (46.15%), hypertension (35.16%), insufficient time to complete studies or onset beyond 3 h after reconfirmation (24.17%) and intracranial hemorrhage (15.93%). Of 167 excluded patients, 72 (43.11%) were excluded by a single criterion, 53 (31.73%) by 2 criteria and 29 (17.36%) by 3 criteria. The mean time from hospital arrival to presentation to a neurologist was 9.24 +/- 15.11 min (n = 164, median = 8.00, mode = 10, range = 0-65). The mean time from hospital arrival to computed tomography (CT) was 21.67 +/- 23.95 min (n = 167, median = 20.00, mode = 10, range = 4-68). An intrahospital stroke code was implemented to minimize intrahospital delay. However, only 11 patients received intravenous rtPA and 4 IA thrombolysis at our hospital from June 2004 to October 2005. The result brings into question the neurologist's conservative interpretation of the criteria and the necessity to clearly define some criteria. Furthermore an intrahospital stroke code should also be implemented for inpatients to maximize the eligibility for rtPA.