Stroke is an emergency

“Time is brain tissue!”1-3

  • Every minute, in which a large vessel ischaemic stroke is untreated, the average patient loses 1.9 million neurons, 13.8 billion synapses, and 12 km of axonal fibres.
  • Each hour in which treatment fails to occur, the brain loses as many neurons as it does in almost 3.6 years of normal aging.
  • The penumbra area (see Pathophysiology section) represents potentially salvageable brain tissue if perfusion of the tissue can be restored in time (before the tissue becomes completely ischaemic and dies).

 

Ischaemic core - Pnumbra

 

Act FAST4,5

Acute stroke is a life-threatening condition that constitutes a medical emergency comparable to acute myocardial infarction.6

  • Rapid admission to hospital following stroke is vital to ensure that eligible patients have timely access to treatments which offer the potential to reduce the extent of ischaemic injury.
  • Therefore, emergency services should be called immediately following the onset of stroke symptoms.7
    • Consultation with a primary care physicians* almost doubles the time from onset to hospital arrival
    • Assessment algorithms in the call centre can help detect a suspected stroke and alert the emergency team and nearest stroke centre
  • Paramedics or emergency doctors at the scene can reliably recognise stroke symptoms after training.8
  • EMS transportation should use priority signals.
  • NINDS recommends a door-to-needle time (DTN) of 1 hour or less.

Streamlining of local guidelines and standard operating procedures may shorten the DTN in experienced stroke centres to <30 min on average.

  • However, only approximately 11% of all stroke patients who are thrombolysed receive rt-PA within 90 minutes of symptom onset.

*Refers to primary care physicians / general practitioners / family doctors and not EMS (emergency medical services)

 

The earlier the treatment, the better the outcome9

  • Most effective are:
    • Early recognition of stroke symptoms, including public education
    • Establishment of stroke networks
    • Prioritisation and direct transfer to specialised stroke centres or stroke units
    • Management by multidisciplinary teams
    • Act fast to initiate treatment with thrombolysis as early as possible
  • Remember: In acute ischaemic stroke, the earlier treatment initiation of thrombolysis is, the more likely to result in a favourable outcome.
References 
  1. Saver JL. Time is brain--quantified. Stroke 2006;37:263-266.
  2. Hacke W, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-774.
  3. NINDS NIH website. Stroke proceedings. Latest update 2008.
  4. González RG. Imaging-guided acute ischemic stroke therapy: From ‘time is brain’ to ‘physiology is brain’. AJNR Am J Neuroradiol 2006;27:728-735.
  5. Donnan GA, et al. Neuroimaging, the ischaemic penumbra, and selection of patients for acute stroke therapy. Lancet Neurol 2002;1:417-425.
  6. Kaste M, et al. Organization of stroke care: education, stroke units and rehabilitation. European Stroke Initiative (EUSI). Cerebrovasc Dis Basel Switz 2000;10 Suppl 3:1–11.
  7. Kothari R., et al. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke1995;26:937-941.
  8. Kothari RU, et al. Emergency physicians. Accuracy in the diagnosis of stroke. Stroke 1995;26:2238-2241.
  9. Act FAST. Stroke.org 2014. Available at: http://www.stroke.org/understand-stroke/recognizing-stroke/act-fast. Accessed April 16, 2018.