Logistics in acute stroke management.

Results from the two National Institute of Neurological Disorders and Stroke (NINDS) studies indicate that administration of alteplase (recombinant tissue-type plasminogen activator; rt-PA) within 3 hours of symptom onset to appropriately selected patients with acute ischaemic stroke improves patient outcome. Several factors that delay time to treatment in patients with stroke have been identified, the most important of which is probably the failure of the patient (or family member) to recognise the signs and symptoms of stroke. Once the need for help is recognised, the initial point of access to emergency medical systems should be the local emergency number (e.g. 911 in the US) rather than the family physician. Patients with suspected stroke should be evaluated and treated by a physician as soon as possible, but this will depend to some extent on the level of expertise of the attending physicians and on available resources. The NINDS-sponsored National Symposium on the Rapid Identification and Treatment of Acute Stroke has recommended ideal time goals for all hospitals that treat patients with acute stroke. These goals include 25 minutes from arrival at an emergency department to computerised tomography scan, and 60 minutes from arrival to treatment. Recommendations for enhancing the logistics of treatment for patients with stroke may involve the following: improved education programmes for at-risk populations and their families and emergency medical system personnel, identification of acute stroke as a level one emergency similar to acute myocardial infarction or trauma, and modelling of treatment algorithms accordingly, acceptance of, and commitment to, the time guidelines recommended by the National Symposium on the Rapid Identification and Treatment of Acute Stroke. Effective and safe use of alteplase will also depend on rapid access to the highest level of neurological and radiological expertise. This may require major changes in the educational curriculum of emergency department residency and ongoing continuing education programmes, and/or more intensive radiological training for neurologists and neurologists-in-training.