title: Extending tissue plasminogen activator use to community and rural stroke patients.
abstract: OBJECTIVE
  Guidelines for intravenous tissue plasminogen activator (tPA) use in stroke emphasize the importance of limiting its use to facilities with imaging capabilities and stroke expertise. This prospective case series set out to evaluate the safety of tPA use in patients referred from rural communities to a tertiary center.
  
  
  METHODS
  Prospective data of 82 consecutive patients treated with tPA in London, Ontario, were reviewed.
  
  
  RESULTS
  Twenty-three patients were transferred to London from a rural hospital (non-London patients); 49 were first evaluated in a London emergency room (London ER); and 10 were inpatients in a London hospital at the time of stroke onset. Mean transfer time and distance to London for non-London patients were 89 minutes and 41 miles. Although symptom onset to London ER times were longer for non-London than for London ER patients (123 versus 53 minutes), the door to needle times were significantly shorter for the former (49 versus 95 minutes, P<0.005). Imaging to needle times were longer for London inpatients compared with London ER patients (55 versus 36 minutes, P=0.16). The proportion of patients with >4-point improvement on the NIH Stroke Scale or cure at 24 hours was 57%, with no difference among groups (P=0.46). The overall symptomatic hemorrhage rate at 36 hours was 2%. No significant differences in outcomes were observed at 3 months.
  
  
  CONCLUSIONS
  This prospective study suggests that it is feasible and safe to treat rural patients referred to a tertiary care center with tPA, thus extending the benefits of thrombolysis for acute stroke to a wider population.
authors.affiliation: Department of Neurology, University of Florida, Jacksonville 32217, USA. jose.merino@jax.ufl.edu
authors.forename: José G
authors.initials: JG
authors.lastname: Merino
authors.forename: Brian
authors.initials: B
authors.lastname: Silver
authors.forename: Edward
authors.initials: E
authors.lastname: Wong
authors.forename: Blaine
authors.initials: B
authors.lastname: Foell
authors.forename: Bart
authors.initials: B
authors.lastname: Demaerschalk
authors.forename: Arturo
authors.initials: A
authors.lastname: Tamayo
authors.forename: Fali
authors.initials: F
authors.lastname: Poncha
authors.forename: Vladimir
authors.initials: V
authors.lastname: Hachinski
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006760:Hospitalization; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D009864:Ontario; D012423:Rural Health; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D014187:Transportation of Patients; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator