Delay in Arrival is Primary Reason Patients With Large Vessel Stroke Do Not Receive Thrombolysis

Document Type


Publication Date

Summer 5-1-2023


Background and Objectives: Intravenous thrombolysis (IVT) is the recommended treatment for acute ischemic stroke (AIS) patients presenting within 4.5 h of stroke onset. In large vessel occlusion stroke (LVOS), IVT appears to have a synergistic effect with endovascular therapy (EVT) resulting in better outcomes than EVT alone. The most cited reasons that patients do not receive IVT are time from stroke onset to hospital arrival >4.5 h and minor/ improving symptoms. Data are lacking about why IVT is not administered in patients with LVOS as these patients usually have clear and significant neurologic deficits. This investigation explores why IVT was not administered to a cohort of patients with LVOS undergoing EVT. Methods: This is an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing paradigms (OPUS-REACH) registry. The OPUS-REACH registry contains patients from eight U.S. health systems (nine endovascular stroke centers [ESCs]) who underwent EVT for LVOS. We excluded patients who had their stroke after hospital arrival or who arrived at the hospital by mobile stroke unit. Statistical analysis was done with simple statistics and compared using T-tests to calculate a p-value. Results: 2010 patients were included our analysis. 39% of patients received IVT. Patients who received IVT were younger (69.4 years v. 71.6 years) and had higher mean National Institutes of Health Stroke Scores (16.6 vs. 15.6). Patients who arrived by ambulance were more likely to receive IVT than those who arrived by private vehicle (40.5% vs. 26.3%). When examining patients who did not receive IVT, 58.7% of patients did not receive IVT because of stroke onset to hospital arrival of >4.5 h. The second most common reason was active anticoagulant use (16.0%). Patients were less likely to receive IVT at primary stroke centers (PSC) than ESCs (34.3% vs. 41.1%). On multivariable analysis, younger age, higher NIHSS, treatment at an ESC, and arrival by ambulance were all associated with increased likelihood of receiving IVT. Conclusion: In this large U.S. study examining why LVOS patients do not receive IVT, the most frequent reason for exclusion continues to be stroke onset to hospital arrival of >4.5 h. The second most common reason was active anticoagulation. As IVT plus EVT improves good functional outcomes in LVOS over EVT alone, efforts must be made to increase public awareness of time-sensitive nature of stroke.

Publication Title

Academic Emergency Medicine




Supplement 1

First Page


Last Page



Society for Academic Emergency Medicine Annual Meeting, SAEM 2023 held 5/16/23 to 5/19/23 in Austin, TX, USA

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Open Access