Outcomes of intravenous thrombolytic therapy for acute ischemic stroke with an integrated acute stroke referral network: initial experience of a community-based hospital in a developing country

Some of the literature encourages the use of intravenous (IV) thrombolytic therapy for acute ischemic stroke (AIS) in centers with no previous experience with this therapy. The benefits of an acute stroke referral network for IV thrombolytic therapy remain controversial, however. We present outcomes of IV thrombolytic therapy for AIS with an integrated acute stroke referral network at an institution with no previous experience in stroke thrombolysis and compare the results with previously published data. A total of 458 patients with AIS or transient ischemic attack (TIA), referred from a hospital in the acute stroke referral network or walk-ins, admitted to the stroke unit of Thammasat Hospital between October 2007 and January 2009 (16 months) were prospectively assessed. The main outcome measures were IV thrombolytic treatment rate, initial National Institutes of Health Stroke Scale (NIHSS) score, door-to-needle time, onset-to-treatment time (OTT), intracerebral hemorrhage, and morbidity and mortality at 3 months after onset. A total of 100 patients (59 from hospitals in the stroke referral network) received IV recombinant tissue plasminogen activator (rt-PA) therapy (21% of the admissions with AIS and TIA); 41% of the patients referred from a hospital in the network received IV rt-PA. The median NIHSS score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125 minutes), and mean OTT was 160 minutes (range, 60-270 minutes). There were 13 asymptomatic intracerebral hemorrhages and 2 symptomatic intracerebral hemorrhages (1 fatal). By 3 months, 42 patients had achieved excellent recovery (modified Rankin Scale score of 0-1), and 14 had died. These outcomes are comparable to data from the National Institute of Neurological Disorders and Stroke and previous studies of IV rt-PA therapy in Thailand. Our findings indicate that integrating an acute stroke referral network into IV thrombolytic therapy for AIS in a community-based setting is safe and feasible and should help increase the rate of thrombolytic therapy. Previously inexperienced community-based centers can reproduce the experience and outcome measures reported by clinical trials and in the landmark literature of IV thrombolytic therapy in patients with stroke.