title: Posterior circulation stroke is associated with prolonged door-to-needle time.
abstract: BACKGROUND
  Lack of recognition of early symptoms of acute posterior circulation ischaemic stroke might delay timely diagnosis and treatment with tissue plasminogen activator.
  
  
  OBJECTIVE
  We hypothesized that patients with posterior circulation stroke receive delayed thrombolytic treatment in comparison to anterior circulation stroke. We investigated the differences in times to evaluation or treatment between patients with anterior circulation ischaemic stroke and posterior circulation stroke in our aim to understand the barriers that might have caused these delays.
  
  
  METHODS
  A cross-sectional study was conducted using consecutive patients presenting to our tertiary academic centre with acute ischaemic stroke who were treated with intravenous tissue plasminogen activator within 4·5 h from symptom onset. We compared demographics, stroke severity, symptoms and signs, and time intervals among onset, emergency department arrival, emergency department physician evaluation, neurologist evaluation, brain imaging, and tissue plasminogen activator treatment in patients with anterior circulation stroke and posterior circulation stroke.
  
  
  RESULTS
  Among 252 patients treated with intravenous tissue plasminogen activator, 12% had posterior circulation stroke. Patients with posterior circulation stroke had significantly lower median baseline the National Institutes of Health and Stroke Scale (NIHSS) score (P = 0·01), higher frequency of nausea (P < 0·01), vomiting (P < 0·01), dizziness (P < 0·01), and lower frequency of aphasia (P = 0·002) or neglect (P = 0·048). The emergency department physician evaluation-to-neurologist evaluation and door-to-needle intervals were significantly longer for posterior circulation stroke patients compared with anterior circulation stroke patients. The neurologist-to-needle time, however, was similar in the two groups. The presence of nausea and vomiting was associated with a longer time from emergency department evaluation to neurology evaluation and had a significant association with delayed treatment.
  
  
  CONCLUSIONS
  Posterior circulation stroke patients had a delay in neurology evaluation after initial emergency department evaluation and a delay in intravenous tissue plasminogen activator administration compared with anterior circulation stroke patients. There may be difficulties in rapidly recognizing the symptoms of posterior circulation stroke, in contrast to anterior circulation stroke, in the emergency department.
authors.affiliation: Department of Neurology, University of Texas Medical School-Houston, UT Health, Houston, TX, USA.|Department of Neurology, University of Texas-Houston, Houston, TX, USA.
authors.forename: Amrou
authors.initials: A
authors.lastname: Sarraj
authors.affiliation: Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Medrek
authors.affiliation: Department of Neurology, Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, AL, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Albright
authors.affiliation: Tulane Stroke Program, Tulane University, New Orleans, LA, USA.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Martin-Schild
authors.affiliation: University of Texas, Houston, TX, USA.
authors.forename: Wafi
authors.initials: W
authors.lastname: Bibars
authors.affiliation: Department of Neurology, University of Texas, Houston, TX, USA.
authors.forename: Farhaan
authors.initials: F
authors.lastname: Vahidy
authors.affiliation: Department of Neurology, University of Texas at Houston Medical School, Houston, TX, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Grotta
authors.affiliation: Department of Neurology, University of Texas-Houston, Houston, TX, USA.
authors.forename: Sean I
authors.initials: SI
authors.lastname: Savitz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020771:Anterior Cerebral Artery / Q000503:physiopathology; D003430:Cross-Sectional Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications; D008297:Male; D008875:Middle Aged; D020769:Posterior Cerebral Artery / Q000503:physiopathology*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: acute stroke therapy; cerebral infarction; ischaemic stroke; rtPA; stroke subtypes; thrombolysis