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The Urgency to Treat Acute Ischemic Stroke

Time Is Brain


Acute ischemic stroke (AIS) is a serious medical emergency. It is critical to assess and manage AIS patients as soon as they arrive in the emergency department of the hospital. In a typical large vessel acute ischemic stroke, 1.9 million neurons are lost each minute.1

Did you know that in 2009, only 27.4% of hospitals participating in the AHA/ASA's Get With the Guidelines registry achieved a door-to-treatment time of ≤60 minutes?2

Click the tabs below to find helpful resources to help your hospital improve door-to-treatment time. You can also submit your best practices, which may help others improve their management of AIS.


The Golden Hour of AIS

Rapid intervention is crucial in the treatment of acute ischemic stroke. In a typical large-vessel acute ischemic stroke1:

  • 32,000 neurons are lost per second
  • 1.9 million neurons are lost per minute
  • 120 million neurons are lost per hour

Door-to-treatment time ≤60 minutes is the standard of care recognized by professional societies and national medical associations.2 The Joint Commission target for primary stroke centers is to achieve a door-to-treatment time of within 60 minutes in 80% or more of patients.1

Door To Treatment *Activase must be administered within 3 hours of symptom onset. Please see the Prescribing Information for full eligibility requirements.

Best practices to reduce door-to-treatment times3-7:

Emergency Department (ED)

  • Have the ED own the door-to-CT scan portion of the Golden Hour and focus on reducing those times
  • Use digital stop clocks to time Golden Hour activities
  • Place posters with stroke signs and symptoms in ED and waiting rooms
  • Keep "stroke toolkit" containing order sets, National Institutes of Health Stroke Scale (NIHSS) tool, and other stroke-related materials
  • Locate CT scanners near ED to reduce transit time
  • Store Activase in ED or near CT scanner, as well as in the pharmacy

Stroke Team

  • Train ED nurses to evaluate all suspected strokes using NIHSS
  • Train ED nurses to reconstitute, dose, and administer Activase® (Alteplase) to all eligible AIS patients*
  • Include CT techs on stroke team pages
  • Train lab techs to analyze and report stroke results STAT
  • Report door-to-treatment times and patient outcomes to ED staff
  • Provide immediate anonymous feedback to the stroke team on each AIS patient case
  • Have regular stroke team meetings to review door-to-CT, lab and treatment times on each AIS patient case

*Activase must be administered within 3 hours of symptom onset. Please see the Prescribing Information for full eligibility requirements.

 

Acute Ischemic Stroke Assessment and Treatment Guidelines

AHA/ASA 2007 guidelines: immediate diagnostic tests for all patients with suspected acute ischemic stroke

  • Noncontrast brain CT or brain MRI
  • Blood glucose
  • Serum electrolytes/renal function tests
  • Electrocardiogram (ECG)
  • Markers of cardiac ischemia
  • Complete blood count (CBC), including platelet count†
  • Prothrombin time (PT)/international normalized ratio (INR)†
  • Activated partial thromboplastin time (aPTT)†
  • Oxygen saturation

† Although it is desirable to know the results of these tests before giving t-PA, thrombolytic therapy should not be delayed while awaiting results unless: (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia; (2) the patient has received heparin or warfarin; or (3) use of anticoagulants is unknown.

AHA/ASA 2007 guidelines: immediate diagnostic tests for selected patients with suspected acute ischemic stroke

  • Liver function tests (LFTs)
  • Toxicology screen
  • Blood alcohol level
  • Pregnancy test
  • Arterial blood gas tests (if hypoxia suspected)
  • Chest X-ray (if lung disease suspected)
  • Lumbar puncture (if subarachnoid hemorrhage suspected and CT scan negative for blood)
  • Electroencephalogram (if seizures suspected)

 

Patient selection for Activase treatment

  • ≥ 18 years of age
  • Measurable neurologic deficit by NIHSS
  • Patient must present within 3 hours of AIS symptom onset
  • Obtain baseline CT to exclude intracranial hemorrhage and other risk factors
  • Review patient history for potential contraindications
  • Certain patient populations that were not studied in Activase clinical trials are not absolutely contraindicated, but require careful consideration of potential risks and benefits if a decision is made to treat

Patients with the conditions below should NOT be treated with Activase. Any of these conditions automatically disqualifies a patient from treatment with Activase.

  • Evidence of intracranial hemorrhage on pretreatment evaluation
  • Suspicion of subarachnoid hemorrhage on pretreatment evaluation
  • Intracranial or intraspinal surgergy, serious head trauma, or stroke in the previous 3 months
  • History of intracranial hemorrhage
  • Uncontrolled hypertension at time of treatment (eg, >185 mm Hg systolic or >110 mm Hg diastolic)
  • Seizure at the onset of stroke
  • Active internal bleeding
  • Intracranial neoplasm, arteriovenous malformation, or aneurysm
  • Known bleeding diathesis, including but not limited to:
    • Current use of oral anticoagulants (eg, warfarin sodium) or an International Normalized Ratio (INR) >1.7 or a prothrombin time (PT) >15 seconds
    • Administration of heparin within 48 hours preceding the onset of stroke and an elevated activated partial thromboplastin time (aPTT) at presentation
    • Platelet count <100,000/mm3

Warnings in acute ischemic stroke

In addition to the conditions listed in the general Warnings section of the full Prescribing Information, the risks of Activase therapy (eg, increased risk of SICH) to treat acute ischemic stroke may be increased in conditions listed here. Therefore, in these situations, the anticipated benefits should be weighed against the potential risks.

  • Abnormal blood glucose (<50 mg/dL or >400 mg/dL)
    • Due to increased risk for misdiagnosis, special diligence is required in making this diagnosis in these patients
  • Severe neurologic deficit (NIHSS>22)
  • Major and early infarct signs on CT
  • Minor neurologic deficit
  • Rapidly improving symptoms

The safety and efficacy of treatment with Activase in patients with minor neurologic deficit or rapidly improving symptoms have not been evaluated. Therefore, treatment of these patients with Activase is not recommended.

 

Bleeding risk with Activase treatment

The most common complication encountered during Activase therapy is bleeding.

  • There are 2 broad categories of bleeding associated with thrombolytic therapy:
    • Internal bleeding, involving intracranial and retroperitoneal sites, or the gastrointestinal, genitourinary, or respiratory tract
    • Superficial or surface bleeding, observed mainly at invaded or disturbed sites (ie, venous cutdowns, arterial punctures, sites of recent surgical intervention)
  • Should serious bleeding (not controlled by local pressure) occur, the infusion of Activase and any concomitant heparin should be terminated immediately

 

Submit Your Best Practices

Have you had success in reducing your hospital's door-to-treatment times for acute ischemic stroke?

You have the opportunity to share your best practices with others! Fill out the entry form below and your submission will be reviewed for possible inclusion on this website in the future.

Check back to see if your best practice is featured and find out what other stroke teams are doing to reduce door-to-treatment times.

Fields marked with an asterisk (*) are required.

*Facility Name:
*Facility Location (City, State):
*Your Name:
* Email address:
* Confirm email address:
* Specialty:
*Door-to-Needle Best Practice:

Please note: All submissions will be reviewed, but not all best practices will be featured on the website.
 

 

Resources

The following are helpful resources on the Golden Hour of acute ischemic stroke and minimizing door-to-treatment times.

Target Stroke

American Heart Association/American Stroke Association (AHA/ASA) Target: Stroke4

Target: Stroke is a national quality improvement initiative of the AHA/ASA to improve outcomes for ischemic stroke patients by helping hospitals achieve door-to-needle times of 60 minutes or less. Target: Stroke advocates the adoptions of 10 best practice strategies for reducing door-to-needle times in acute ischemic stroke.

Visit www.strokeassociation.org/targetstroke for more information about Target: Stroke and ways to your hospital can participate.

 

Order or Download Materials

By clicking the buttons below, you will be redirected to the resources page where you can order or download the materials.

Resources

Golden Hour Poster<br/>(25 posters per pack) Golden Hour Poster
DOWNLOAD/ORDER
Stroke Assessment Card Ring Stroke Assessment Card Ring
ORDER

 

Image Library

Stopwatch image Golden Hour Stopwatch
DOWNLOAD

*Activase must be administered within 3 hours of symptom onset. Please see the Prescribing Information for full eligibility requirements.
Rectangular image Golden Hour Linear Timeline
DOWNLOAD

*Activase must be administered within 3 hours of symptom onset. Please see the Prescribing Information for full eligibility requirements.

 

Articles and Publications

These useful articles may help you reduce your hospital's door-to-treatment time.

Genentech is neither affiliated with nor endorses the following publications.

Adams HP Jr, Del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–1711.

American Academy of Neurology (AAN) Practice advisory: thrombolytic therapy for acute ischemic stroke—summary statement. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1996;47(3):835–839.

Fonarow GC, Smith EE, Saver JL, et al. Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750–758.

Jauch EC. The "golden hour" of acute ischemic stroke: treatment guidelines & recommendations. The Internet Stroke Center website. http://www.strokecenter.org/wp-content/uploads/2011/08/The-Golden-Hour-of-Acute-Ischemic-Stroke.pdf. Accessed November 28, 2011.

Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: adult stroke. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3): S818–S828.

Saver JL. Time is brain—quantified. Stroke. 2006;37:263–266.

Target: Stroke Best Practice Strategies. http://www.heart.org/HEARTORG/HealthcareResearch/TargetHFStroke/TargetStroke/Target-Stroke-Best-Practice-Strategies_UCM_307825_Article.jsp#.TtXc-mMk6nB. Accessed November 28, 2011.

 

Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Important Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Saver JL. Time is brain — quantified. Stroke. 2006;37:263-266.
2.
Smith, E and Brice J. Target: Stroke webinar series, integrating stroke teams and EMS systems: working together to improve stroke outcomes.
3.
The "golden hour" of acute ischemic stroke: treatment guidelines & recommendations. The Internet Stroke Center website. http://www.strokecenter.org/wp-content/uploads/2011/08/The-Golden-Hour-of-Acute-Ischemic-Stroke.pdf. Accessed November 28, 2011.
4.
Adams HP Jr, Del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.
5.
Target: Stroke Best Practice Strategies. http://www.heart.org/HEARTORG/HealthcareResearch/TargetHFStroke/TargetStroke/Target-Stroke-Best-Practice-Strategies_UCM_307825_Article.jsp#.TtXc-mMk6nB. Accessed November 28, 2011.
6.
Jauch EC, Cucchiara B, Adeoye O, et al. Part 11: adult stroke. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3): S818-S828.
7.
Data on file. Genentech USA, Inc.