Late Hospital Arrival for Thrombolysis after Stroke in Southern Portugal: Who Is at Risk? Sofia Sobral, MD,* , † Isabel Taveira, MD,* , † Rui Seixas, MD,* , † Ana Cl audia Vicente, MD,* , † Josiana Duarte, MD,* , † Ana Teresa Goes, MD,* , † David Dur an, MD,* , † Jo~ ao Lopes, MD,* , † Henrique Rita, MD,* , † ,1 and Hip olito Nzwalo, MD, MSc† , ‡ Background: Delayed hospital arrival remains the main reason for the low rates of thrombolysis in eligible acute ischemic stroke (AIS) patients. The role of socioeco- nomic and clinical factors for the prehospital delay of AIS remains poor and has never been studied in Portugal. Objectives: Describe the socioeconomic and clinical factors leading to delayed hospital admission of AIS patients eligible to thromboly- sis. Methods: A case-control study with a consecutive thrombolyzed AIS patients from 2010 to 2015. Controls were patients who did not receive thrombolysis because of late hospital arrival. Logistic regression with stepwise forward regres- sion analysis was used to identify independent predictors of delayed admission to receive thrombolysis with intravenous tissue-type plasminogen activator (rtPA). Results: Of the 1247 patients admitted with AIS, 76 (6%) arrived on-time and received intravenous rtPA. Controls were 65.8% (146/222) of the total number of patients included in the study. Overall, the mean age was 73 years (§11, 61), a minority were below 60 years, and 43.7% were women. Being beneficiary of social insertion income (odds ratio [OR]: .286; .124-.662, P = .003), not having any telephone contact (OR: .145; .039-.536, .004) or having exclusive landline (.055; .014-.210, <.001) and posterior circulation stroke (OR: .266; .087-.811, P = .020) decreased the likelihood of hospital arrive on-time rtPA. The use of prehospital ambulance services increased (OR: 6.478; 2.751-15.254, P < .001) the odds of ER on- time arrival for thrombolysis. Conclusions: Poverty, lack of stroke awareness, or difficulties in requesting immediate medical help are the main factors implicated in late-hospital admission for thrombolysis in AIS. Stroke awareness campaigns, pro- motion of activation of national emergency number and stroke code can increase the rate of thrombolysis. Key Words: Thrombolysis—hospital arrival—late—stroke © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. Introduction The chain of events leading to the final outcome of stroke patients starts immediately after symptoms onset. Thrombolysis with tissue-type plasminogen activator (rtPA) should be initiated as soon as possible within 4.5 hours after stroke onset. 1 In acute ischemic stroke (AIS) patients with indication of mechanical thrombectomy, bridging rtPA is also recommended and may improve the prognosis. 2,1 Hence, for the majority of AIS patients, rtPA remains the most important reperfusion intervention. From the *Department of Internal Medicine, Hospital do Litoral Alentejano, Set  ubal, Portugal; †Stroke Unit, Hospital do Litoral Alentejano, Santiago do Cac em, Portugal; and ‡Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal. Received July 8, 2018; revision received October 9, 2018; accepted December 8, 2018. Address correspondence to Hip olito Nzwalo, MD, MSc, Universidade do Algarve, Departamento de Ci^ encias Biom edicas e Medicina, Edifício 7 Ala Nascente- 3° andar, Campus de Gambelas, 8005-139 Faro, Portugal. E-mailes: nzwalo@gmail.com, hipolito.nzwalo@gmail.com. 1 Monte do Gilbardinho EN 261, 7540-230 Santiago do Cac em, Portugal. 1052-3057/$ - see front matter © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.12.009 Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2018: &&À&& 1 ARTICLE IN PRESS