Introduction: Administration of tPA in the first 60 min post-onset, the golden hour (GH), is associated with improved functional outcomes but remains unachievable in the vast majority of patients. We sought to identify independent predictors of IVT in the GH in a prospective, multi-center study.
Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Demographics, vascular risk factors, onset to treatment time, door-to-needle time (DTN) admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. The etiopathogenic mechanism of AIS was documented using TOAST criteria. Subjects with in-hospital stroke or treated in the mobile stroke unit were excluded.
Results: Out of total 658 IVT-treated AIS patients (mean age 64±15 years; 50% men; median NIHSS-score 6, IQR: 4-12) we identified 26 (4%) subjects treated in the GH (mean age 62±15 years; 46% men; median NIHSS-score 8, IQR: 4-12). GH patients had shorter median DTN (23 min, IQR: 18-44 vs. 38 min, IQR: 26-49). DTN230 min was more prevalent in the GH group (62% vs. 20%; p<0.001). DTN emerged as the only independent predictor of IVT in the GH in multivariable logistic regression models adjusting for demographics, risk factors, admission blood pressure and serum glucose levels, TOAST subtype, baseline NIHSS and ASPECTS. A 10-min delay in DTN approximately halved the odds of IVT in the GH (OR: 0.54; 95%CI: 0.41-0.71; p<0.001). Alternatively, DTN equal or less than 30min increased exponentially the likelihood of tPA initiation in the GH (OR: 6.29; 95%CI: 2.78-14.25; p<0.001).
Conclusions: Shorter DTN is the only independent predictor of IVT initiation within the GH. Continued improvements in systems of acute stroke care should aim to further reduce DTN in order to increase the availability of tPA delivery in the GH.