Experience with t-PA treatment in a large South American city

Early thrombolysis with intravenous recombinant tissue plasminogen activator (t-PA) reduces disability following ischemic stroke. However, only a small fraction of the potential candidates receive therapy. We studied the proportion of eligible patients who did not receive t-PA and the reasons therapy was withheld from patients admitted to a Brazilian university hospital.

From July 1996 to June 1997, each suspected case of hyperacute ischemic stroke led to the immediate evaluation by a research physician. Patients first seen in primary care centers near the research hospital were to be rapidly transferred. Reasons for patient exclusion were detailed.

Fifty-six patients were evaluated; only 5 received t-PA therapy. The main reason for not receiving t-PA (34 cases) was late hospital arrival. This was caused by lack of recognition of the early stroke signs (n=13); delayed personal or family response (n=7); wrong medical orientation (n=4); and late patient transportation (n=10). A computed tomographic (CT) scand could not be done fast enough to allow therapy in 8 patients. Nine of 14 patients in whom neurological evaluation and CT scan were done within the 3-hour period were also excluded. The main reason was refusal of informed consent (n=5). Only a few patients were excluded because of medical contraindications (n=3) or the presence of early mass effect (n=1).

The main factor limiting access of patients with ischemic stroke to t-PA therapy in Rio de Janeiro is a low public awareness of early stroke symptoms and of the need for urgent hospital evaluation. Public education, an efficient transport system for suspected stroke patients, and optimization of the use of available CT scanners could have a significant impact on the number of treated patients.