NASSER GHADEER S ALSHAMARI,ABDULLAH NUDRI M ALOTAIBI,SHAHAD BEDAIWI MOHAMMED ALBEDAIWI,SAGIR KHALAF M ALSHAMMARI,AHMAD ABDULLAH AL MADHARI,LUJAIN OBAID A ALANAZI
DOI: https://doi.org/Background: Thrombolytic therapy is a critical intervention for acute ischemic stroke (AIS), with outcomes heavily dependent on door-to-needle time (DTN). Despite advancements, delays persist, prompting the implementation of various workflow optimizations in emergency department (ED) settings. This systematic review evaluates the effectiveness of thrombolytic therapy in EDs, focusing on DTN reduction strategies, comparative efficacy of thrombolytic agents (alteplase vs. tenecteplase), and clinical outcomes.
Methods: Following PRISMA guidelines, a comprehensive search was conducted across PubMed, Web of Science, Scopus, and Embase. Studies assessing thrombolytic therapy in ED settings, reporting DTN times, clinical outcomes (e.g., NIHSS, mRS), or workflow interventions (e.g., stroke teams, telemedicine) were included. Two independent reviewers screened, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool.
Results: Eight studies (n = 82–165 patients per study) were included. Stroke team activation, pre-hospital alerts, and protocol-driven pathways (e.g., "emergency green channel") significantly reduced DTN (median range: 30–85.5 min, p < 0.001). Faster DTN correlated with improved functional recovery (mRS 0–2: 49% at 3 months) in some studies, though others found no NIHSS improvement despite reduced DTN. Tenecteplase showed shorter DTN (30 vs. 36 min, p = 0.006) versus alteplase, with comparable safety profiles. High decision-making reliability (κ = 0.74) and faster assessments (6 vs. 33 min, p < 0.001) were observed. Symptomatic intracranial hemorrhage occurred in 5–6.7% of cases, with lower rates in protocol-optimized cohorts.
Conclusion: Protocol-driven thrombolysis in EDs significantly improves DTN times, but clinical benefits vary by patient-specific factors. Telemedicine and tenecteplase offer promising efficiencies, though further randomized trials are needed to assess long-term outcomes.
