Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy.
OBJECTIVE
The effectiveness of intravenous thrombolysis in acute ischemic stroke is time dependent. The effects are likely to be highest if the time from symptom onset to treatment is within 60 minutes, termed the golden hour.


OBJECTIVE
To determine the achievable rate of golden hour thrombolysis in prehospital care and its effect on outcome.


METHODS
The prospective controlled Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke study was conducted in Berlin, Germany, within an established infrastructure for stroke care. Weeks were randomized according to the availability of a specialized ambulance (stroke emergency mobile unit (STEMO) from May 1, 2011, through January 31, 2013. We included 6182 consecutive adult patients for whom a stroke dispatch (44.1% male; mean [SD] age, 73.9 [15.0] years) or regular care (45.0% male; mean [SD] age, 74.2 [14.9] years) were included.


METHODS
The STEMO was deployed when the dispatchers suspected an acute stroke during emergency calls. If STEMO was not available (during control weeks, when the unit was already in operation, or during maintenance), patients received conventional care. The STEMO is equipped with a computed tomographic scanner plus a point-of-care laboratory and telemedicine connection. The unit is staffed with a neurologist trained in emergency medicine, a paramedic, and a technician. Thrombolysis was started in STEMO if a stroke was confirmed and no contraindication was found.


METHODS
Rates of golden hour thrombolysis, 7- and 90-day mortality, secondary intracerebral hemorrhage, and discharge home.


RESULTS
Thrombolysis rates in ischemic stroke were 200 of 614 patients (32.6%) when STEMO was deployed and 330 of 1497 patients (22.0%) when conventional care was administered (P < .001). Among all patients who received thrombolysis, the proportion of golden hour thrombolysis was 6-fold higher after STEMO deployment (62 of 200 patients [31.0%] vs 16 of 330 [4.9%]; P < .01). Compared with patients with a longer time from symptom onset to treatment, patients who received golden hour thrombolysis had no higher risks for 7- or 90-day mortality (adjusted odds ratios, 0.38 [95% CI, 0.09-1.70]; P = .21 and 0.69 [95% CI, 0.32-1.53]; P = .36) and were more likely to be discharged home (adjusted odds ratio, 1.93 [95% CI, 1.09-3.41]; P = .02).


CONCLUSIONS
The use of STEMO increases the percentage of patients receiving thrombolysis within the golden hour. Golden hour thrombolysis entails no risk to the patients' safety and is associated with better short-term outcomes.


BACKGROUND
clinicaltrials.gov Identifier: NCT01382862.
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Martin
M
Ebinger
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Alexander
A
Kunz
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Matthias
M
Wendt
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Michal
M
Rozanski
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Benjamin
B
Winter
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Carolin
C
Waldschmidt
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Joachim
J
Weber
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Kersten
K
Villringer
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Jochen B
JB
Fiebach
Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany2Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Heinrich J
HJ
Audebert
D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D010960:Plasminogen Activators / Q000627:therapeutic use; D011446:Prospective Studies; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome
D010960:Plasminogen Activators