If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke?

Abstract

Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.

Keywords: emergency medical services; prehospital delay; stroke; thrombolysis; tissue plasminogen activator.

Figure 1

Median onset-to-door times after stroke and percentages of patients arriving to hospital after stroke at 1, 2, 3, 6, and 24 h. (A) Data points represent median onset-to-door times (hours) of stroke patients plotted against the year/s of data acquisition, in studies of factors associated with hospital arrival times after stroke, from 58 studies. For studies conducted over multiple years, the mean of the years was taken (8). Black line shows the local polynomial regression (LOESS), and the horizontal gray line indicates 3 h. (B) Median onset-to-door times (hours) from two studies that reported data for multiple years, from the United States (USA) (54) and Greece (59). Black lines connect data from the same study. (C) Subset of median onset-to-door time data in panel (A) showing studies from the United States (–33, 35, 36, 44, 48, 53, 54, 73), excluding one outlier of median 16 h in 2000–2001 (128). (D) The cumulative percentages of patients arriving to hospital after stroke, at 1, 2, 3, 6, and 24 h after onset. Data points represent percentages from individual studies plotted against year/s of data acquisition. Black line shows the local polynomial regression (LOESS). An improvement in prehospital delay over the years would manifest as an upwards curve within each box, which is not seen. (E) Subset of the cumulative percentage of patients arriving before 2 h from studies that reported on data for multiple years from Italy [1986–1990 to 1991–1995 (71); 2004–2012 (83)] and the United States [2001–2004 (54), 2003–2009 (62)].