ASA recommends 60-minute limit for door-to-needle time for stroke
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
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
“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
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
“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
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,”
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
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.