thrombolysis with recombinant tissue plasminogen activator ( rtpa , alteplase ) is the only effective specific treatment for acute ischemic stroke patients coming in window ( 4.5 h from onset of symptoms ) . a milestone study of national institute of neurological disorders and stroke in 1995 , demonstrated the benefits of rtpa in to patients of acute ischemic stroke ( ais ) who came within window period . these patients of ais who were thrombolysed were 30% more likely to survive with minimal disability resulting in a 12% absolute increase in the proportion having excellent functional outcomes at 3 months . stroke study iii trail ( 2008 ) window period was extended to 4.5 h. for every 15 min reduction in door to needle time ( dtnt ) there is 5% reduction in odds of in hospital mortality ( odd ratio , 0.95 ; 95% confidence interval , 0.92 - 0.98 : p = 0.0007 ) . all patients who presented with stroke to emergency department ( er ) from january 2011 to december 2013 were included in the study . after initial assessment by causality personnel a medical / neuro - resident evaluated the patient . radiological diagnosis was obtained with noncontrasted brain computed tomography and/or diffusion weighted magnetic resonance imaging ( dwi ) . after neuro physician opinion or after telephonic discussion by neuro - resident with neuro physician ( telestroke ) the treatment plan was decided . for the patients who presented within window period thrombolysis was planned . severity of stroke was documented by the national institutes of health stroke scale ( nihss ) contra - indications for thrombolysis were checked and consent of relatives / patient was taken . those patients who presented out of window period ( > 4.5 h after onset of symptom / symptom to door time [ std ] > 4.5 h ) , or patients who had hemorrhagic stroke and those who were not willing for giving consent were excluded [ figure 1 ] . algorithm for patient presenting with stroke in emergency room ( protocol used in the study ) patients record files and charts were used to extract retrospective data . the collected data use to evaluate er to needle [ door to needle time-(dtnt ) ] time and reasons for delay in thrombolysis therapy in acute stroke patients . the following parameters were studied 
 onset of symptoms to er time , assessment by physician / medical chief resident time ( door to physician time [ dtpt])er to imaging time ( door to imaging time [ dtit]),er to needle time ( dtnt)contraindications for thrombolysis . onset of symptoms to er time , assessment by physician / medical chief resident time ( door to physician time [ dtpt ] ) er to imaging time ( door to imaging time [ dtit ] ) , er to needle time ( dtnt ) contraindications for thrombolysis . the onset of symptom time for patients with wake up was accepted as last time the patient was seen as healthy . the baseline characteristics of patient with acute ischemic stroke brought / admitted to er , clinical features , arrival time ( door time ) to er , severity of stroke , imaging time , radiological findings , contraindication for thrombolytic treatment , time of starting recombinant tissue plasminogen activator ( rt - pa ) and thereafter complications were recorded [ table 2 ] . the data abstracted were transferred to the spss 17.0 program ( spss statistics is a software package used for statistical analysis . it is statistical package for social science and is produced by spss inc . ) of the computer for statistical analysis . six hundred and ninety - five patients with symptoms of stroke were presented to our emergency department in the study period . out of these five hundred and forty seven ( 78.7% ) were excluded as they had come out of window period that is , they had arrived 4.5 h after the onset of stroke symptoms . algorithm for patient presenting with stroke in er ( protocol used in the study ) . further after imaging of these one hundred and forty eight patients , one hundred four ( 70.27% ) were excluded . sixty - two ( 59.6% ) had intra cerebral bleed , 1 ( 0.9% ) had hemoglobin - 3.1 g , 13 ( 13% ) of them had transient ischemic attack ( neurological symptoms improved ) and dwi images of these patient were normal . 6 ( 5.7 ) patients were diagnosed to have metabolic de - rrangement ( hypoglycemia , hyperglycemia , hyponatremia ) . other reasons for exclusion in our study were post - ictal status , financial problem , recent thrombolysis , recent surgery , and delay in contacting senior radiologist [ table 1 ] . distribution of contraindications for thrombolytic therapy of patients baseline clinical characteristics of thrombolysed patients ( n=44 ) total 44 ( 29.7% ) patients with ais were thrombolysed . thirty - four ( 79.5% ) were male and nine ( 20.45% ) were female . co - morbid illness in the form of hypertension 6 ( 13.6% ) , diabetes 2 ( 4.5% ) , ischemic heart diseases ( ihd ) 2 ( 4.5% ) , previous stroke cva 3 ( 6.5% ) , > 1 co - morbidity ( ht / cva / dm / ihd / hypothyriod ) 19 ( 43% ) , seizure 1 ( 2% ) and alcoholic liver diseases 1 ( 2% ) patients respectively . the mean time for arrival of patients from onset of symptoms to hospital ( std ) 1.23 h ( 15 min-3 h ) . the mean door to neuro - physician time dtpt was 32 min ( 5 min-2.23 h ) . the mean dtnt 1.44 h ( 40 min-3.3 h ) [ tables 3 and 4 ] , [ figures 24 ] . our study dtpt , dtit and dtnt compared with aha guideline interval number of patients thrombolysed per hour door to physician time door to imaging time ( recommended standard time :  45 min ) analysis of our study clearly states that stdt , dtpt , dtit , and dtnt time are significantly more . thus , we had many hurdles in delivering thrombolysis therapy to these 44 patients . only 7 ( 15% ) patients had dtnt  60 min . the problems / barriers in our study were categorized into three factors : mean symptom to door time was 83 min ( median : 69 ) . poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital . public and emergency medical services staff education play important role in shortening the pre hospital period . in our study - door to physician , door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] . there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit . thus lack of triaging stroke patient at all level of intervention was our weakest point . in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time . the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al . lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms . study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa . lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug , we have started keeping rtpa in our drug stock our dtnt was 104 min ( door to needle time median - 100 ) . relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden . one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) . transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay . poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital . public and emergency medical services staff education play important role in shortening the pre hospital period . in our study - door to physician , door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] . there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit . thus lack of triaging stroke patient at all level of intervention was our weakest point . education of emergency medical services of stroke symptoms will help to triage stroke patient . in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time . the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al . lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms . study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa . lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug , we have started keeping rtpa in our drug stock our dtnt was 104 min ( door to needle time median - 100 ) . relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden . one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) . transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay . poor recognition of stroke signs , especially in older patients caused delay in arrival time to hospital . public and emergency medical services staff education play important role in shortening the pre hospital period . in our study - door to physician , door to imaging and door to needle time were significantly ore compared to standard recommendations ( aha ) [ table 3 ] . there was lack of handling stroke patients with high priority at each level er , imaging unit , stroke unit . thus lack of triaging stroke patient at all level of intervention was our weakest point . education of emergency medical services of stroke symptoms will help to triage stroke patient . in one of the patients the on call doctor was very busy attending emergency calls so causing increase in dtpt time . the concept of having second on call doctor who takes care only of patients with acute stroke has being recommended by kobayashi et al . lack of triaging at radiology unit and performing entire sequences of magnetic resonance imaging ( mri ) scan lead to increase in dtit . thus again dwi has high sensitivity ( 88 - 100% ) and specificity ( 95 - 100% ) for detecting infarcted regions , within minutes of onset of symptoms . study suggested  brain attack team mri sequence  of < 10 min to confirm acute ischemia stroke and assess candidacy for iv - rtpa . lack of triaging of bed for stroke patients resulted in increase in dtnt time . to prevent these delay we started thrombolysing ais patient in er . to prevent delay due to inavailability of drug our dtnt was 104 min ( door to needle time median - 100 ) . patient with raised blood pressure requiring labetalol infusion caused delay . relatives with geriatric patient ( 79 years ) took longer time to give consent due to age of the patient and secondly due to financial burden . one of our patients had liver diseases so we had to wait for international normal ratio report for prothrombin time ( international normalized ratio ) . transient ischemic attack patients were not thrombolysed , but in latter half of study dwi images helped us to prevent delay . the barriers of thrombolysis in our study included : 
 lack of public awareness and inaccessiblity to emergency medical serviceslack of prioritizing triage system at er , radiology unit and stroke unitlack of a multi - disciplinary stroke care team . lack of public awareness and inaccessiblity to emergency medical services lack of prioritizing triage system at er , radiology unit and stroke unit lack of a multi - disciplinary stroke care team . a multi - disciplinary stroke care team consists of well - established emergency medical services , physicians , neurologist , nurses , radiology staff , neuro - radiologist , and pharmacist . forming a one - call comprehensive  stroke code  will help in co - ordination at all level . time to time audit of quality indicator of stroke code team may help to overcome the factors for delay in dtnt .