Dear Editor

We pose the question what are the most important barriers for thrombolytic therapy in ischemic stroke patients?

Cerebrovascular disease is the second common cause of the death in the world. Intravenous thrombolysis is the only approved therapy for acute ischemic stroke patients and its safety and efficacy has been established [1], Nonetheless, in developing countries, thrombolytic therapy for acute ischemic stroke patients is available only for 1–3% of patients and mostly in urban areas [2]. Iran is a developing country with stroke prevalence of more than 100 per 100 000 population [3]; however, a very limited number of centers are providing this treatment to patients. For finding the most important barriers for thrombolytic therapy, during a one-year study period, any patient who met the Cinncinati Stroke Scale enrolled at our study. Six hundred forty-seven patients (mean age was 69 and 52·2% were female) enrolled. After lab study and CT scanning, 515(79·4%) patients were diagnosed as ischemic stroke. One hundred fifty-nine (31·3%) patients were arrived at the hospital in the first three-hours of symptoms onset. Among these patients, 131 (82·3%) missed thrombolytic therapy due to delayed performance of brain CT scanning and laboratory tests and 61 (38·3%) due to having other tissue plasminogen activator contraindications (some of patients had both). Mean time interval between hospital arrival to completing CT scan was 91 min, and hospital arrival to complete investigations (door to needle time) was 147 min. Exclusion criteria for early arrived patients are shown in Table 1. Only 16 (3·1%) patients of all cases remained eligible for thrombolytic therapy.

Table 1. Exclusion criteria other than time for rtPA in acute ischemic patients
 No. (%)
Clearing spontaneously67 (13·1)
Minor stroke symptoms (NIHSS score <5)98 (19·1)
Major deficit (NIHSS score >22)39 (7·6)
History of recent trauma or ischemic stroke (>3 months)16 (3·1)
Myocardial infarction in the previous three-months3 (0·6)
Recent major surgery (<14 days)1 (0·2)
SBP > 185 or DBP > 11069 (13·5)
INR > 1·717 (3·4)
aPTT > 40 s35 (7·1)
Platelet < 100 000/mm312 (2·4)
Glucose < 50 mg/dl2 (0·4)
Seizure at onset21 (4·1)
Hypodensity > 1/3 of cerebral hemisphere37 (7·2)

The main barriers for implementation of thrombolytic therapy in developing countries are: delay in arrival of patients at the emergency department after symptoms onset, which is mainly due to poor recognition of stroke symptoms among public and lack of rapid transportation to the hospital; financial constraints because of high cost of the drug; lack of proper treatment facilities; physicians fear of serious side effects of the drug specially intracranial hemorrhage; and lack of faith of the part of physicians regarding the efficacy of thrombolytic therapy [2]. Based on results of this study, the most important barrier to implementing thrombolytic therapy for acute ischemic stroke patients were in-hospital delays such as initial patient assessment, performing CT scan, and lab studies and shows that in hospitals which has the required infrastracture, initiating a fast-track system could have a significant impact on rising the eligibility rate of this patients.


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  2. References
  • 1
    Hacke W, Donnan G, Fieschi C, Kaste M, Kummer RV. Association of outcome with early stroke treatment: pooled analysis of ATLANT, ECASS, and NINDS rt-PA stroke trials. Lancet 2004; 363:768774.
  • 2
    Pandiana JD, Padma V, Vijaya P, Sylaja PN, Murthy JMK. Stroke and thrombolysis in developing countries. Int J Stroke 2007; 2:1726.
  • 3
    Hosseini AA, Sobhani-Rad D, Ghandehari K, Benamer HTS. Frequency and clinical patterns of stroke in Iran – systematic and critical review. BMC Neurol 2010; 10:72.