Intravenous thrombolysis during inter-hospital transfer of acute stroke patients is safe and efficient

Background: Intravenous thrombolysis (IVT) in acute stroke is increasingly performed in community hospitals. In selected cases such as persistent basilar artery occlusion (BAO) consecutive endovascular mechanical thrombectomy (EMT) may be indicated. However, this treatment option demands transfer to specialized stroke centres. We prospectively investigated safety and efficiency of IVT during earthbound inter-hospital transfer of acute stroke patients. Patients and methods: Starting in 2006, we implemented a prospective treatment protocol for acute stroke patients, by which IVT was started in near-by cooperating community hospitals and continued during immediately arranged transfer to our centre for on-demand EMT. Inclusion criteria were evidence of BAO or carotid T occlusion (CTO) in the absence of contraindications for IVT. The predefined time window for IVT was three hours in CTO and six hours in BAO. Results: Between January 2006 and December 2007 a total of 23 patients were treated. All patients received IVT (rt-PA 0.9mg/kg) during inter-hospital transfer. In 19 patients BAO (n=16) or CTO (n=3) were confirmed by CT angiography (CTA), in the remaining four patients BAO was clinically suspected without unequivocal radiological evidence. In the 19 patients with proven BAO or CTO, IVT alone led to recanalization in ten (53%). Consecutive EMT was performed in the remaining nine patients and led to recanalization in six (67%). One patient with extensive cerebellar infarction presented with delayed secondary hemorrhage two to twelve hours after IVT. Three months after treatment, 15 of 23 patients (65%) were still alive, 13 of them (57%) had a good to moderate outcome with a modified Rankin score of three or less. Conclusion: IVT during inter-hospital transfer seems to be safe and efficient in acute BAO and CTO. It may minimize treatment delay and maximize the odds of recanalization in acute stroke patients admitted to community hospitals in which the combination of IVT with on-demand EMT is considered.