Thrombolytic Refusal Over Telestroke

Area of Science:

• Neurology
• Emergency Medicine
• Health Services Research

Background:

• Tissue plasminogen activator (tPA) refusal rates for acute ischemic stroke (AIS) range from 4%-6% in emergency departments.
• Telestroke (TS) services have improved tPA accessibility but introduced communication challenges impacting informed consent.
• This study investigated tPA refusal incidence and reasons within a TS network.

Purpose of the Study:

• To determine the rate of tPA refusal in a telestroke network for AIS patients.
• To identify patient characteristics associated with tPA refusal.
• To understand the primary reasons for tPA refusal in the TS setting.

Main Methods:

• Analysis of the Lone Star Stroke Consortium Telestroke Registry (September 2015 - December 2018).
• Inclusion of AIS patients eligible for tPA within 4.5 hours of symptom onset.
• Comparison of baseline characteristics and clinical outcomes between tPA acceptors and refusers.

Main Results:

• 8% of 1,242 eligible AIS patients refused tPA.
• Female, non-Hispanic Black patients, and those with prior stroke history were more likely to refuse tPA.
• Reasons for refusal included mild/improving symptoms and concerns about side effects; no significant difference in good outcomes (90-day mRS 0-2) was observed between groups.

Conclusions:

• tPA refusal rates in telestroke are comparable to traditional settings.
• No significant difference in clinical outcomes exists between AIS patients who accept or refuse tPA.
• Further research into sex and racial disparities in tPA refusal is needed to ensure equitable treatment decisions.