- Primary prevention: public information in order to increaseawareness
- Acute phase management, from the activation of the emergency service tothe rehabilitation and early secondaryprevention
- Health care for survivors withdisability
Materials and Methods
- The adoption of an internal protocol as “priority pathway” in the ER
- Neurologist pre-alerting from the territory
- Immediate TC scanning availability
Uncertainty about symptom onset
- Incorrect triage
Original from 
- Severe stroke (NIHSS >25)
- Age > 80 years
- Patients on anticoagulants
- Recent surgery/trauma
- Patients over the 4.5 hours, showing “mismatch” areas on advanced neuroimaging
- A dedicated “stroke team” (ER physician - neurologist - neuro-radiologist - radiology technician - nurse) pre-alerted by 118 or ER triage. This team must be readily available when the patient enters the ER.
- The use of weighing beds, each of them coming with a chronometer to optimize the treatment performance
- An advanced standardized neuro-imaging protocol
- Early administration of rt-PA in the ER or TC, postponing any other time-wasting procedure (chest x-rays, ECG, etc.)
We observed no correlation with the outcome (mRS after 3 months) when comparing ON-label and OFF-label treatments.
- Outcome was better in patients with an initial NIHSS <10
- Early ischemic signs on the basal brain TC correlate with worse outcomes
- Considering the stroke site (according to the BAMFORD classification), the best outcome was shown after strokes involving small vessels (in particular, lacunar types) or the anterior circulation
- Symptomatic hemorrhagic complications correlate with worse outcomes.
- Sander M, Saskia S, Lonneke M.L. de Laub, Renske M and Nyika D. Short Door-to-needleTimes in acute ischemic stroke and prospective identification of its delaying factors Cerebrovasc Dis Extra. 2015 May-Aug; 5(2):75–83
- Guidetti D, Larrue V, Lees KR, et al. Thrombolysis with Alteplase 3 to 4.5 Hours afterAcute Ischemic Stroke. The New England journal of medicine.2008;359(13):1317–1329.
- Gregg C. Fonarow MD, Eric E. Smith MD, MPH, Jeffrey L. Saver, MD, Mathew J. Reeves PhD, Deepak L. Bhatt MD, Circulation AHA.Timeliness of Tissue Plasminogen Activator Therapy in AcuteIschemicStroke:PatientCharacteristics, HospitalFactors,andOutcomesAssociatedwith Door-to-Needle Times within 60Minutes
- Meretoja A1, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste M. Reducingin-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012 Jul24;79(4):306-13.
- Gregg C. Fonarow, MD1; Xin Zhao, MS2; Eric E. Smith, MD, MPH3; Jeffrey L. Saver, MD4; Mathew J. Reeves, PhD5;Door-to-Needle Times for Tissue Plasmino-gen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative JAMA. 2014;311(16):1632-1640.