Treatment Goals

Time is brain! 

• As a stroke progresses, human nervous tissue is rapidly and irreversibly lost. 
  1. For every minute an ischemic stroke is untreated, the average patient loses approximately 1.9 million neurons 
  2. Penumbra: a salvageable zone around the area of infarction 
  3. Goal

the goal of treatment and early intervention is to salvage as much brain tissue as possible to prevent further ischemia  

• Time
  1. Symptom onset is <4.5 hours
     • To be a candidate for fibrinolytic treatment one must present within 4.5 hours of symptom onset
     • Symptom onset (time symptoms manifested) is NOT the time a patient is found with symptoms
  2. Patients who wake up with symptoms or have unclear time of onset (>4.5 hours last known well) 
     • WAKE-UP trial 
       1. Evaluated: patients who woke up with a stroke or those with unclear time of onset (4.5 of stroke recognition) 
       2. Imaging: MRI used to determine if there is a mismatch 
          • Abnormal signal in diffusion weighted imaging (DWI) and no visible signal change on fluid attenuated inversion recovery (FLAIR)
       3. Outcome: Treatment with alteplase improved functional outcome and did not increase the risk of death or major bleed
  3. Symptom onset within 6-24 hours 
     • May be a candidate for mechanical thrombectomy 
  4. Door to needle time 
     • Within 60 minutes