ASA recommends 60-minute limit for door-to-needle time for stroke sufferers

7 February 2013

People having an ischemic stroke should receive clot-dissolving therapy, if appropriate, within 60 minutes of arriving at the hospital, according to new American Stroke Association guidelines published in the American Heart Association journal Stroke.

It also says the window for clot-dissolving therapy may be extended to 4.5 hours from the start of symptoms for carefully selected patients.

Ischemic stroke, which accounts for nine in 10 strokes, is caused by a blood clot in the arteries leading to the brain. Calling emergency services immediately after recognizing any of the warning signs of stroke — and getting  to a stroke centre as fast as possible — are still the most important steps for optimal stroke care.

During an acute stroke, physicians must quickly evaluate and diagnose the patient as soon as possible to determine if patients are eligible to receive the clot-dissolving drug recombinant tissue plasminogen activator (tPA), which must be given within hours of symptom onset. The goal is to minimize “door-to-needle” time which provides the patient with the best opportunity for benefit from the treatment.

“tPA can now be considered for a larger group of patients, including some those who present up to 4.5 hours from stroke onset,” said Edward Jauch, M.D., lead author of the guidelines and director of the Division of Emergency Medicine at the Medical University of South Carolina.

The new guidelines recommend:

  • integrating regional networks of comprehensive stroke centres (which offer 24/7, highly specialized treatment for all types of stroke);
  •  primary stroke centres (which provide 24/7 specialized care mainly for ischemic stroke); and
  • acute stroke-ready hospitals (which can evaluate and treat most strokes but lack highly specialized capabilities), and community hospitals. 

“This is the first time we’ve brought these healthcare elements together, including community hospitals which may lack onsite stroke expertise, which reflects the emerging role of telemedicine in these hospitals,” Jauch said.

Among other major revisions to the guidelines, if feasible, patients should be rapidly transferred to the closest available certified primary care stroke centre or comprehensive stroke centre, which might involve air medical transport.

“However, for patients brought to hospitals without specialized stroke expertise, telemedicine can provide real-time access to expertise,” Jauch said. “If such a hospital partners with a primary or comprehensive stroke centre and uses telemedicine, early treatment decisions can be made for patients. If the patient had to be transferred before administering some therapies, it would be too late.”

Other key recommendations in the new guidelines include:
Multidisciplinary quality improvement (QI) committees should be created within hospitals to review and monitor stroke care quality. “We now have dozens of studies showing the benefit of QI programs,” Jauch said.

Recently introduced stent retrievers could potentially remove large blood clots more completely and quickly than tPA. But the devices shouldn’t be a substitute for intravenous tPA and should only be used in clinical studies to determine if they improve patient outcomes.

F.A.S.T. is an easy way to remember the sudden signs of a stroke:

  • Face drooping: Does one side of the face droop or is it numb?
  • Arm weakness: Is one arm weak or numb?
  • Speech difficulty: Is speech slurred, are you unable to speak, or are you hard to understand?
  • Time to call emergency services — 911/ 112/ 999 (depending on country): If you have any of these symptoms, even if the symptoms go away, call an ambulance  and get to the hospital immediately.


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