Estimation of Iranian Stroke Patients Eligible for Intravenous Thrombolysis with tPA

Most governments in developing countries are not in a position to provide thrombolysis therapy in non-private hospitals (1). Patients must cover the costs using their own personal savings or not receive treatment (1). Tissue plasminogen activator (tPA) for use in acute ischemic stroke has been approved by health insurance companies in only a few of the developing countries (1, 2). Medical centers with infrastrucure for thrombolysis in stroke patients are very limited in the developing countries, however stroke units is available in a few developing countries including Iran (1, 2). All of the ischemic stroke patients admitted in Ghaem center, Mashhad, Iran during January-June 2008 enrolled in a prospectice observational study. Ghaem center is a tertiary care hospital which has infrastructure for thrombolysis with tPA. Stroke onset to hospital enterance time, hospital enterance to completed investigation time, contraindications of thrombolysis and capability of patients to afford treatment by their own were recorded in whom arrived hospital in 3 hours time window (2, 3). There is no priority for triage of stroke patients in Iranian emergency divisions. 625 ischemic stroke patients were evaluated and 50 stroke patients (30 males, 20 females), 8% arrived hospital within a three hour time window. Half of this 50 stroke patients were delivered to the hospital by ambulance. The mean stroke onset to hospital enterance time in ambulance and non-ambulance groups of these 50 stroke patients is 75.4 and 98.3 minutes respectively. The mean hospital enterance to completed investigations time in ambulance and non-ambulance groups of these 50 cases was 116.2 and 116.6 minutes respectively. 44% of this early arrived stroke patients remained within three hour time window at completed CTand laboratory tests. 30% of these cases were capable to pay tPA expense by themselves. The most important barrier of thrombolysis with tPA in our center is its uncoverage by Iranian health insurance systems in stroke patients. Contraindications of thrombolysis with tPA were found in 58% of these early arrived stroke patients. Seven patients (five males, two females) which constituted 14% of early arrived stroke patients and 1.1% of whole ischemic stroke patients were eligible for intravenous thrombolysis. Meanwhile 86% of early arrived group of our stroke patients (43/50) missed thrombolysis therapy due to delay in investigations and presence of the contraindications. Delay in performance of CTand laboratory tests excluded 56% of these 50 patients from the three hour time window and is a main problem of this therapy in Iran. This delay is due to lack of periority for candidates of thrombolysis in performance of triage, CT and laboratory tests. Centers with resources to give intravenous and intraarterial tPA are limited to some urban areas in the developing world (4). Although about 14 hospitals have this resource and infrastructure in Iran, however these medical centers cover less than one third of Iranian stroke patients. These limitations diminishes the chance of Iranian stroke patients for taking thrombolysis with tPA.