Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

Carlos Abanto, Ana Valencia, Pilar Calle, Danny Barrientos, Néstor Flores, María Novoa, Rosa L. Ecos, Jorge Alonso Ramirez, Angela K. Ulrich, Joseph R. Zunt, David L. Tirschwell, Sarah Wahlster

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


BACKGROUND: The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest.

AIMS: To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases.

METHODS: We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression.

RESULTS: Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity.

CONCLUSIONS: Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Original languageEnglish (US)
Article number104819
JournalJournal of Stroke and Cerebrovascular Diseases
Issue number7
StatePublished - Jul 2020

Bibliographical note

Funding Information:
Funding: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43 TW009137 .

Publisher Copyright:
© 2020 Elsevier Inc.


  • Peru
  • Thrombolysis
  • acute ischemic stroke
  • acute stroke treatment
  • global health
  • latin America
  • tPA
  • Thrombolytic Therapy/adverse effects
  • Prospective Studies
  • Humans
  • Middle Aged
  • Male
  • Recovery of Function
  • Feasibility Studies
  • Time Factors
  • Fibrinolytic Agents/administration & dosage
  • Aged, 80 and over
  • Adult
  • Female
  • Disability Evaluation
  • Length of Stay
  • Stroke/diagnosis
  • Time-to-Treatment
  • Quality Indicators, Health Care
  • Treatment Outcome
  • Administration, Intravenous
  • Tissue Plasminogen Activator/administration & dosage
  • Aged
  • Developing Countries

PubMed: MeSH publication types

  • Observational Study
  • Journal Article


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