title: Understanding the reasons behind the low utilisation of thrombolysis in stroke.
abstract: BACKGROUND
  Thrombolysis remains the only approved therapy for acute ischaemic stroke (AIS); however, its utilisation is reported to be low.
  
  
  OBJECTIVE
  This study aimed to determine the reasons for the low utilisation of thrombolysis in clinical practice.
  
  
  METHODS
  Five metropolitan hospitals comprising two tertiary referral centres and three district hospitals conducted a retrospective, cross-sectional study. Researchers identified patients discharged with a principal diagnosis of AIS over a 12-month time period (July 2009-July 2010), and reviewed the medical record of systematically chosen samples.
  
  
  RESULTS
  The research team reviewed a total of 521 records (48.8% females, mean age 74.4 ± 14 years, age range 5-102 years) from the 1261 AIS patients. Sixty-nine per cent of AIS patients failed to meet eligibility criteria to receive thrombolysis because individuals arrived at the hospital later than 4.5 hours after the onset of symptoms. The factors found to be positively associated with late arrival included confusion at onset, absence of a witness at onset and waiting for improvement of symptoms. However, factors negatively associated with late arrival encompassed facial droop, slurred speech and immediately calling an ambulance. Only 14.7% of the patients arriving within 4.5 hours received thrombolysis. The main reasons for exclusion included such factors as rapidly improving symptoms (28.2%), minor symptoms (17.2%), patient receiving therapeutic anticoagulation (6.7%) and severe stroke (5.5%).
  
  
  CONCLUSIONS
  A late patient presentation represents the most significant barrier to utilising thrombolysis in the acute stroke setting. Thrombolysis continues to be currently underutilised in potentially eligible patients, and additional research is needed to identify more precise criteria for selecting patients for thrombolysis.
authors.affiliation: Faculty of Pharmacy, University of Sydney.
authors.forename: Ashraf
authors.initials: A
authors.lastname: Eissa
authors.forename: Ines
authors.initials: I
authors.lastname: Krass
authors.forename: Christopher
authors.initials: C
authors.lastname: Levi
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sturm
authors.forename: Rabsima
authors.initials: R
authors.lastname: Ibrahim
authors.forename: Beata
authors.initials: B
authors.lastname: Bajorek
keywords: Alteplase; Cerebrovascular accident; Stroke; Thrombolysis; Tissue Plasminogen Activator (tPA)