Stroke centers worldwide recognize the concept “Time is Brain,” which encourages rapid stroke intervention to maximize patient outcomes. In an acute stroke setting, intervention with chemo-thrombolysis — as supported by the NINDS trial — or combined intravenous-tissue plasminogen activator (IV-tPA) intrarterial (IA) intervention (MR CLEAN, ESCAPE, and EXTEND-IA) are essential tools in arresting stroke progression.

However, recent recommendations from the American College of Emergency Physicians (ACEP) may be clouding the critical decision-making essential during emergency stroke care.

Under the new ACEP recommendations, IV-tPA is a Level B recommendation for patients presenting within 3 hours of stroke onset who meet NINDS criteria, rather than a Level A recommendation — a dramatic change in stroke management. Traditionally, Level B recommendation is for patients meeting the ECASS III criteria up to 3 to 4.5 hours of symptom onset. ACEP says, “IV-tPA may be carefully given to patients within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.” Notably, the U.S. FDA limits use of IV-tPA to within 3 hours of stroke onset.

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ACEP also has a level A recommendation to consider risk of hemorrhagic conversion with IV-tPA use, advising, “The increased risk of symptomatic intracerebral hemorrhage must be considered whether to administer IV-tPA to acute ischemic stroke patients.” ACEP also includes a Level C recommendation for counseling the patient and family on use of IV-tPA in the setting of acute stroke, which could diminish the importance of the urgency of use IV-tPA in the acute stroke scenario.

The idea of not initiating thrombolytic therapy in an acute stroke patient until the patient and family discuss the option to treat with IV-tPA is of concern to most physicians. The main problem is that the stroke scenario is ongoing: 1.9 million neurons die every minute and every delay of 30 minutes results in a 10% worsening of the NIHSS score. The class C recommendation will result in unnecessary worsening of the NIHSS score, delay in treatment, and worsening of the Rankin scale at three months.

A secondary concern raised by some members of the Emergency Department community is for IV-tPA use in stroke mimics. The current neurologic literature points to a 1% complication rate in the setting of a stroke mimic, providing all guidelines are met for IV-tPA administration. It is important that all protocols in the evaluation of patients for thrombolytic therapy be followed in exact detail to minimize risk.