Intravenous tissue plasminogen activator (tPA) remains the only level 1A treatment for acute ischemic stroke. The results of several prospective randomized trials comparing tPA with standard treatment and pooled analyses confirm the relationship of treatment success with time from symptom onset to initiation of treatment.1-6 However, despite 2 decades of efforts to streamline systems of care including formation of designated stroke centers, placement of CT scanners in emergency departments (EDs), in-house 24/7 stroke teams, and recognition that dedicated neurological ED pathways can speed treatment, only approximately 5% of stroke patients are treated, and most are treated beyond 2 hours from symptom onset when tPA is less effective. The main reason is lack of public recognition of stroke symptoms and failure of patients to quickly seek care at a nearby institution or activate emergency medical services, such as by calling 911. Another important reason within the control of physicians and other health care personnel to reduce the time is the inherent delay caused by ED triage, registration, evaluation, testing, and treatment. The median door-to-needle times for tPA administration in stroke center EDs in the United States has exceeded 60 minutes with little improvement since the drug was first approved in the United States in 1996.7
Grotta JC. tPA for Stroke: Important Progress in Achieving Faster Treatment. JAMA. 2014;311(16):1615–1617. doi:10.1001/jama.2014.3322
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