Elsevier

The Lancet Neurology

Volume 12, Issue 6, June 2013, Pages 585-596
The Lancet Neurology

Review
Streamlining of prehospital stroke management: the golden hour

https://doi.org/10.1016/S1474-4422(13)70100-5Get rights and content

Summary

Thrombolysis with alteplase administered within a narrow therapeutic window provides an effective therapy for acute ischaemic stroke. However, mainly because of prehospital delay, patients often arrive too late for treatment, and no more than 1–8% of patients with stroke obtain this treatment. We recommend that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy. Measures for improvement include continuous public awareness campaigns, education of emergency medical service personnel, the use of standardised, validated scales for recognition of stroke symptoms and for triaging to the appropriate institution, and advance notification to the receiving hospital. In the future, use of telemedicine technologies for interaction between the emergency site and hospital, and the strategy of treatment directly at the emergency site (mobile stroke unit concept), could contribute to more efficient use of resources and reduce the time taken to instigate treatment to within 60 min—the golden hour—of the onset of the symptoms of stroke.

Introduction

Stroke is the most frequent cause of permanent disability in adults and one of the most frequent causes of death.1, 2 In addition to substantial individual suffering, stroke results in enormous costs to society.3, 4 Intravenous thrombolysis with alteplase is an effective treatment for acute ischaemic stroke, as shown in several randomised and placebo-controlled multicentre studies.5, 6, 7, 8, 9 The approved time window for stroke treatment after the onset of symptoms ranges from 3·0 h to 4·5 h in various countries. However, even within this time window, the benefit of treatment strongly decreases as time passes (the so-called time-is-brain concept).10, 11 The same time-sensitivity can be expected with novel endovascular treatment options.12

The number needed to treat with intravenous alteplase for a good outcome, defined as a modified Rankin score of 0–1, has been calculated at 4·5 if treatment is initiated within 1·5 h after the onset of symptoms.7, 13 This number doubles to 9 if treatment is initiated between 1·5 h and 3·0 h after symptom onset, and reaches 14·1 if treatment is delivered between 3·0 h and 4·5 h after onset7 (smaller numbers needed to treat might have been achieved if the modified Rankin scale had been used in its original full seven-level version). For every minute a large-vessel stroke goes untreated, an estimated maximum of 1·9 million neurons and 14 billion synapses are potentially lost, suggesting that even small differences in time to reperfusion could produce clinically relevant differences.14

In this Review of prehospital stroke management we emphasise that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy.

Section snippets

Prehospital stroke management to reduce treatment delay

Before alteplase can be delivered, a complex diagnostic work-up (including neurological examination, imaging, and laboratory analysis) is necessary for exclusion of haemorrhage, diseases mimicking stroke, and other contraindications. This work-up consumes crucial time, often precluding treatment within the approved therapeutic window. Although in some experienced specialised centres administration of intravenous altepase to 20–30% of patients with ischaemic stroke within 3 h is possible,15, 16

Delay in seeking medical attention

Delay in seeking medical attention after the onset of stroke symptoms is an important reason for the underuse of thrombolytic therapies.36, 37, 38, 39, 40 Reported delays in seeking treatment range from 38 min to 4 h.41, 42, 43, 44, 45 Between 24% and 54% of patients with stroke do not call for help within 1 h,41, 45, 46 and many do not seek medical care at all. Reports suggest that only 38–65% of patients use EMS.23, 27

Much evidence suggests, however, that the use of EMS is a crucial variable

Educational programmes for EMS personnel

A great potential for optimisation of stroke management lies with the EMS. The structures of EMS are highly variable between countries and even between states or areas of individual countries.90, 91 Therefore, generalisation of the results of studies in one setting to other settings is difficult. Fairly good evidence already exists for several factors, such as the effectiveness of educational programmes for EMS personnel, the use of instruments for symptom recognition, priority transport to

Use of ambulances as clinical laboratories for research on stroke treatments

Interest is increasing in diagnostic and therapeutic approaches for use in the prehospital phase of stroke management; such approaches might allow responders to reach the patient at a time when the chance of rescuing ischaemic brain tissue is highest. Several ambulance-based studies have been done or are underway on topics including diagnostic measures such as ultrasound140 or electrical impedance tomography for detection of haemorrhage141, 142 and therapeutic approaches such as neuroprotection

Conclusion

This Review clearly shows that every link in the prehospital stroke rescue chain matters and must be further studied for potential improvements. Further research is needed to establish the most effective public awareness programmes that can affect behaviour in an actual emergency situation. Guideline-recommended measures, such as ongoing EMS education, use of stroke recognition scales, triage to hospitals with stroke expertise, and advance notification to the receiving hospitals, should be

Search strategy and selection criteria

We identified references for this Review by searching PubMed for articles published between Jan 1, 1980, and Dec 31, 2012, that contained the terms “prehospital” and “stroke”; “stroke management”; “emergency medical service” and “stroke”; or “thrombolysis” and “stroke”. We also identified articles through searches of reference lists and our own files. We reviewed only articles published in English, focusing on originality and relevance to the broad scope of this Review.

References (172)

  • N Sikka et al.

    Understanding diversity among prehospital care delivery systems around the world

    Emerg Med Clin North Am

    (2005)
  • VL Roger et al.

    Heart disease and stroke statistics—2012 update: a report from the American Heart Association

    Circulation

    (2012)
  • J Olesen et al.

    The economic cost of brain disorders in Europe

    Eur J Neurol

    (2012)
  • Tissue plasminogen activator for acute ischemic stroke

    N Engl J Med

    (1995)
  • W Hacke et al.

    Thrombolysis with alteplase 3 to 4·5 hours after acute ischemic stroke

    N Engl J Med

    (2008)
  • The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial

    Lancet

    (2012)
  • JR Marler et al.

    Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study

    Neurology

    (2000)
  • GC Fonarow 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)
  • P Khatri et al.

    Good clinical outcome after ischemic stroke with successful revascularization is time-dependent

    Neurology

    (2009)
  • JL Saver

    Time is brain—quantified

    Stroke

    (2006)
  • JC Grotta et al.

    Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000

    Arch Neurol

    (2001)
  • A Meretoja et al.

    Reducing in-hospital delay to 20 minutes in stroke thrombolysis

    Neurology

    (2012)
  • PA Barber et al.

    Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility

    Neurology

    (2001)
  • IL Katzan et al.

    Utilization of intravenous tissue plasminogen activator for acute ischemic stroke

    Arch Neurol

    (2004)
  • MD Hill et al.

    Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study

    CMAJ

    (2005)
  • MJ Reeves et al.

    Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry

    Stroke

    (2005)
  • D Tong et al.

    Times from symptom onset to hospital arrival in the Get with the Guidelines–Stroke program 2002 to 2009: temporal trends and implications

    Stroke

    (2012)
  • J Kwan et al.

    A systematic review of barriers to delivery of thrombolysis for acute stroke

    Age Ageing

    (2004)
  • KR Evenson et al.

    A comprehensive review of prehospital and in-hospital delay times in acute stroke care

    Int J Stroke

    (2009)
  • SC Menon et al.

    Critical factors determining access to acute stroke care

    Neurology

    (1998)
  • CR Lacy et al.

    Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.)

    Stroke

    (2001)
  • F Harraf et al.

    A multicentre observational study of presentation and early assessment of acute stroke

    BMJ

    (2002)
  • O Agyeman et al.

    Time to admission in acute ischemic stroke and transient ischemic attack

    Stroke

    (2006)
  • Prehospital and hospital delays after stroke onset–United States, 2005–2006

    MMWR Morb Mortal Wkly Rep

    (2007)
  • JH Lichtman et al.

    Hospital arrival time and intravenous t-PA use in US academic medical centers, 2001–2004

    Stroke

    (2009)
  • H Jin et al.

    Factors associated with prehospital delays in the presentation of acute stroke in urban China

    Stroke

    (2012)
  • M Pitt et al.

    Will delays in treatment jeopardize the population benefit from extending the time window for stroke thrombolysis?

    Stroke

    (2012)
  • M Bouckaert et al.

    Reducing prehospital delay in acute stroke

    Nat Rev Neurol

    (2009)
  • AM Pancioli et al.

    Public perception of stroke warning signs and knowledge of potential risk factors

    JAMA

    (1998)
  • MJ Reeves et al.

    Knowledge of stroke risk factors and warning signs among Michigan adults

    Neurology

    (2002)
  • VJ Howard et al.

    Care seeking after stroke symptoms

    Ann Neurol

    (2008)
  • D Kleindorfer et al.

    Temporal trends in public awareness of stroke: warning signs, risk factors, and treatment

    Stroke

    (2009)
  • BE Anderson et al.

    Knowledge of tissue plasminogen activator for acute stroke among Michigan adults

    Stroke

    (2009)
  • WD Rosamond et al.

    Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study

    Acad Emerg Med

    (1998)
  • R Handschu et al.

    Emergency calls in acute stroke

    Stroke

    (2003)
  • KC Chang et al.

    Prehospital delay after acute stroke in Kaohsiung, Taiwan

    Stroke

    (2004)
  • L Mandelzweig et al.

    Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke

    Stroke

    (2006)
  • I Mosley et al.

    Stroke symptoms and the decision to call for an ambulance

    Stroke

    (2007)
  • P Wester et al.

    Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Seek-Medical-Attention-in-Time Study Group

    Stroke

    (1999)
  • DL Morris et al.

    Prehospital and emergency department delays after acute stroke: the Genentech Stroke Presentation Survey

    Stroke

    (2000)
  • Cited by (0)

    View full text