Implementation of Intravenous Thrombolysis at Community Hospitals followed by Definitive Intra-Arterial Thrombolysis at a Comprehensive Stroke Center

초록

Background: Combined intravenous and intra-arterial thrombolysis is a promising therapeutic strategy for a unified primary-comprehensive stroke center system, with IV TPA initiated in community hospitals and continued during secondary transfer, followed by IA therapy should clot persist on arrival at a comprehensive center. Systematic analysis has not previously been performed of IV-IA therapy among patients presenting first to community hospitals. Methods: We prospectively registered combined IV-IA thrombolysis cases from 1998 to 2001. Following the IMS trial regimen, patients were treated within 3 h of onset with bridging dose IV TPA, 0.6 mg/kg over 30 minutes. If clot persisted at angiography, an additional 0.3 mg/kg TPA was delivered IA. Results: Forty-three patients received bridging dose IV tPA, including 22 with IV treatment start at an outside hospital and 21 with IV treatment start at the UCLA Stroke Center. Mean patient age was 74 (27-97), 19 male, 24 female. Among the 43 patients, 6 improved markedly after IV therapy and did not proceed to angiography. Among 37 patients undergoing angiography, 28 received further IA thrombolysis, with no occluded vessel visualized in 9. Median pre-thrombolysis NIHSS was 15 for the outside hospital IV TPA start group and 20 for the comprehensive hospital IV TPA start group. Mean time from stroke onset to ED arrival was 66.1+25 minutes for the outside start group versus 59.8+37.8 minutes for the comprehensive start group, mean time to the initial CT was 105.3+40.5 versus 93.8+29, to IV tPA start 141.4+32.2 versus 149+27.8, and to angiography 227+60.4 versus 201.3+47.3 (differences not statistically significant). Good functional outcome (Rankin < 3) was achieved in 55% of outside start patients versus 52% of comprehensive start patients, while death occurred in 18% vs 19%. Conclusions: Bridging dose IV/IA TPA initiated in community hospitals can yield rapid start of IA treatment and good functional outcomes.