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Rural use of tPA in acute stroke
Lorraine L. Edwards reviewed charts from 1998 to 2004 and assessed 493 patients presenting to a rural emergency department with stroke symptoms and their experience with tPA. Thirty-four percent arrived within the 3-hour treatment window and 13% of appropriate candidates received tPA, a treatment rate of 4%. None of the patients had intracerebral hemorrhage and none died.
see page 292
Using tPA for acute stroke in a rural setting
Commentary by Patrick D. Lyden, MD, FAAN
Thoughtful physicians no longer question the safety or efficacy of rt-PA for acute stroke, but widespread use remains an elusive goal. Although nationally rt-PA use hovers around 4%, use rates of 15 to 20% have been documented in stroke centers.1 To use rt-PA safely requires little more than physician commitment to champion a stroke team and to persuade the hospital administration to run the CT scanner 24/7; arrange for a laboratory to handle Code Stroke specimens stat; and train nursing staff to triage potential patients promptly. If the National Institute of Neurological Disorders and Stroke protocol for rt-PA for acute stroke is followed, rt-PA is safe; if not, it is risky.2,3 The treatment protocol is simple and broadly inclusive compared to recent stroke clinical trial protocols.4 Therefore, there is no reason a Code Stroke protocol could not be implemented in nearly any typical community hospital that chooses to dedicate resources to acute stroke therapy.
In 1998, a 100-bed community hospital in rural Nebraska did just that.5 By 2004, a retrospective chart review found 439 patients with stroke ICD-9 codes. About one-third of the patients presented within 3 hours, as in most other studies.1,6 rt-PA was given to 4% and there was only one protocol violation; symptomatic ICH occurred in no patients. Eleven patients who did not receive rt-PA were thought after review to have been eligible. Four patients with slight deficits were excluded. If these 15 patients had been treated the use rate in this study would have been 7%.
This impressive study confirms that a Code Stroke team can be set up in most settings. About a third of all stroke patients present within 3 hours, and up to 20% of all ischemic strokes could be treated with rt-PA if resources were available. Most stroke patients arrive too late, confirming the need for public education and ways to identify salvageable brain other than by looking at a clock. Mild and rapidly improving patients are often excluded, as in this trial, but 30% of such patients have a poor outcome and one could argue they should have been treated.6 Nevertheless, although more patients might have been treated, 19 patients would have been left untreated in this community without the dedicated stroke team, a lesson for every community that lacks an organized stroke response system.
see page 292
References
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