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Earlier thrombolysis improves stroke outcomes

Survival and independence greater when treatment starts within 90 minutes

Louise Prime

Wednesday, 19 June 2013

People are more likely to survive stroke and to be discharged home able to walk independently if they are given thrombolytic treatment within 90 minutes of symptom onset, US research has shown. Authors of the large study, published today in JAMA, say their results underline the importance of efforts to get patients to present sooner, and to treat them fast.

The researchers examined data on 58,353 people, with a median age of 72 years, who presented to 1395 US hospitals with acute ischaemic stroke between April 2003 and March 2012. They looked at the effect of the time of onset to treatment (OTT) with intravenous tissue-type plasminogen activator (tPA) on various outcomes – including in-hospital mortality, intracranial haemorrhage, discharge to home and being able to walk independently at discharge.

The median OTT time was 144 minutes; it tended to be shorter when stroke severity was higher, when patients arrived by ambulance, and when they presented during ‘regular hours’. Only 9.3% of people were treated within 90 minutes of symptom onset; OTT was 91-180 minutes in 77.2% of people; and OTT was 181-270 minutes in the remaining 13.6%.

For every 15-minute reduction in OTT, there were reductions in in-hospital mortality and symptomatic intracranial haemorrhage, and increases in the likelihood of being discharged to home and of being able to walk independently at discharge. Compared with patients treated at 181-270 minutes, those treated within 90 minutes had 26% lower mortality, 28% lower risk of intracranial haemorrhage. They were also 33% more likely to be discharged to home and 51% more likely to be walking independently by discharge.

The authors said earlier research had shown that therapy with tPA could benefit some patients up to 4.5 hours after symptom onset, and that time to treatment strongly influenced the magnitude of treatment benefit, but that because these studies were modest in size their generalisability to clinical practice had been limited.

They concluded: “These findings support intensive efforts to accelerate patient presentation and to streamline regional and hospital systems of acute stroke care to compress OTT times.”

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