Time is brain! 

  • As a stroke progresses, human nervous tissue is rapidly and irreversibly lost. 
    1. For every minute an ischemic stroke is untreated, the average patient loses approximately 1.9 million neurons 
    2. Penumbra: a salvageable zone around the area of infarction 
    3. Goal

the goal of treatment and early intervention is to salvage as much brain tissue as possible to prevent further ischemia  

  • Time
    1. Symptom onset is <4.5 hours
      • To be a candidate for fibrinolytic treatment one must present within 4.5 hours of symptom onset
      • Symptom onset (time symptoms manifested) is NOT the time a patient is found with symptoms
    2. Patients who wake up with symptoms or have unclear time of onset (>4.5 hours last known well) 
      • WAKE-UP trial 
        1. Evaluated: patients who woke up with a stroke or those with unclear time of onset (4.5 of stroke recognition) 
        2. Imaging: MRI used to determine if there is a mismatch 
          • Abnormal signal in diffusion weighted imaging (DWI) and no visible signal change on fluid attenuated inversion recovery (FLAIR)
        3. Outcome: Treatment with alteplase improved functional outcome and did not increase the risk of death or major bleed
    3. Symptom onset within 6-24 hours 
      • May be a candidate for mechanical thrombectomy 
    4. Door to needle time 
      • Within 60 minutes