Barriers to Intravenous Alteplase within 4.5 Hours of Acute Ischemic Stroke Onset
Kumnualsilp S, MD1, Buranasakda M, MD1, Gaysonsiri D, MD2, Ienghong K, MD1, Apiratwarakul K, MD1, Tiamkao S, MD3
Affiliation : 1 Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 2 Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand 3 Division of Neurology, Department of Medicine, Faculty of Medicine. Khon Kaen University, Khon Kaen, Thailand
Background : Stroke is the leading cause of death and disability. Nowadays, the standard treatment is Intravenous thrombolytic with
alteplase (t-PA) within 4.5 hours after the stroke onset. However, some patients who arrived to the hospital within 4.5 hours after
stroke onset haven’t received the alteplase.
Objective : To investigate the barriers to thrombolysis drug (alteplase) in acute ischemic stroke patients who arrived at the hospital
within 4.5 hours after the stroke onset.
Materials and Methods: A retrospective study of ischemic stroke patients who developed stroke symptoms and arrived at the
hospital within 4.5 hours but did not receive the thrombolytic drug (non-treatment group). Data were collected at the North-East
hospital of Thailand from the hospital stroke registry and the patient record from October 2014 to September 2015. The study
focused on the reasons for which this group of patients was excluded from receiving the thrombolytic drug. Factors associated
with the non-treatment group were investigated using multivariable logistic regression.
Results : Of a total 229 patients who were diagnosed with acute ischemic stroke and arrived within 4.5 hours after stroke onset, 61
patients underwent thrombolytic therapy with alteplase. Of the 168 patients who did not receive the alteplase, the main reasons
for this were mild or improving symptoms, contraindication to alteplase and uncertain onset time (including wake-up strokes).
Factors associated with the non-treatment group were door time over three hours and patients who had an underlying history of
hypertension or an old cerebrovascular accident (CVA). These patients were less likely to receive the thrombolytic drug. While
patients with a National Institute of Health Stroke Scale (NIHSS) between 8 and 12, were more likely to receive the treatment.
Conclusion : Barriers to use of the thrombolytic drug in acute ischemic stroke in Thai patients included mild or improved symptoms,
relative contraindication to alteplase and uncertain onset time. In order to increase alteplase administration, the revision of relative
contraindication in mild symptoms, seizure at onset of stroke and wake-up stroke or stroke with an uncertain time of onset should
be considered. The application of neuroimaging can be useful to select the eligible cases.
Keywords : Acute ischemic stroke, Thrombolytic therapy, Alteplase, t-PA, rt-PA, r-tPA
