Time is Brain: Variations in Acute Stroke Care are Harmful

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.

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.