Is your next stroke patient outside treatment window? Don't be so sure

Study calls for extending time frames right away

A patient reports stroke symptoms that began four hours ago — outside the window for treatment with intravenous tissue plasminogen activator (IV tPA).

Does this frustrating scenario sound familiar? This patient would now be treated in many EDs, due to compelling new evidence that the time frame can safely be extended to 4½ hours. Of 321 patients given IV tPA or a placebo at three to 4½ hours after symptom onset, more had favorable outcomes who received treatment (52.4% vs. 45.2%), and death rates did not differ between the two groups.1

"The study demonstrates enhanced quality of life for a larger number of patients, virtually without any increased risk," says Joyce McIntyre, RN, MSN, clinical nurse specialist for the ED at Massachusetts General Hospital (MGH) in Boston. "This is a high-quality study that supports extending the time frame to administer tPA, for patients who meet the criteria."

MGH's ED is evaluating giving tPA beyond the three-hour window. In the past five years, a total of 133 patients came to the ED between three and 4½ hours after the onset of stroke and did not receive tPA. "These patients would now meet the requirement," says McIntyre.

The study's findings are "exciting and very compelling," according to Lee H. Schwamm, MD, FAHA, vice chairman of the Department of Neurology and director of TeleStroke and Acute Stroke Services at MGH.

"This is an important advance in the field of acute stroke care and demonstrates that well-designed studies of reperfusion therapy can extend the benefits beyond the three-hour window," says Schwamm.

When should you change your ED's protocols to include patients who arrive up to 4½ hours after onset of symptoms? "Immediately," according to J. Stephen Bohan, MD, MS, FACP, FACEP, executive vice chairman of the Department of Emergency Medicine at Brigham and Women's Hospital in Boston. A well-constructed randomized study is "about the best proof that you can get," says Bohan. "It took patients who could be treated between three and 4½ hours and randomized them to no treatment and treatment, and treatment was beneficial," he says. "It showed fairly distinct benefits."

University of California, San Diego Medical Center's ED sees "many patients that arrived marginally after the three-hour window and did not receive the therapy because they were 15 minutes late," reports Tia Moore, RN, CEN, clinical nurse educator. Patients in this "grey area" now will be treated, she says. "We currently err on the side of good patient care and will administer the thrombolytic."

Currently, very few ED patients are able to be treated with tPA, says Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX. "Opening this window to 4½ hours would immediately increase utilization," Brandt says.

EDs will adopt the new time frame "probably starting right away," she says. "I really think this will change practice — if nothing else, for those people who get here who we miss by minutes. That will probably be the first step toward adoption. Then they'll start expanding the window more and more," says Brandt.

Recently, a 52-year-old man treated at Brackenridge's ED had an initial National Institutes of Health Stroke Score (NIHSS) of four, but within 30 minutes it progressed to a 10. The man was given a normal noncontrast CT scan, a CT perfusion study with a clear deficit and a normal CT angiogram. At four hours after onset of symptoms, the patient was given IV tPA after discussion with him and his family.

"In addition, informed consent was obtained since it was clearly outside of the time window," says Brandt. "The patient responded well to the tPA, and his NIHSS decreased back to a 5."


  1. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1,317-1,329.


For more information about treatment of stroke patients in the ED, contact:

  • Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, Stroke Center Coordinator, The Stroke Center at Hartford (CT) Hospital. Phone: (860) 545-2183, ext. 5. Fax: (860) 545-1976. E-mail:
  • Stephen Bohan, MD, MS, FACP, FACEP, Executive Vice Chairman of the Department of Emergency Medicine, Brigham and Women's Hospital, Boston. E-mail:
  • Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain & Spine Center, Brackenridge Hospital, Austin, TX. Phone: (512) 324-7782. Fax: (512) 324-7051. E-mail:
  • Stacey Claus, RN, BSN, CNRN, Clinical Instructor, Department of Nursing, Cleveland Clinic. E-mail:
  • Joyce McIntyre, RN, MSN, Clinical Nurse Specialist, Emergency Department, Massachusetts General Hospital, Boston. Phone: (617) 643-3589. E-mail:
  • Tia Moore, RN, CEN, Clinical Nurse Educator, Emergency Department, University of California, San Diego Medical Center. E-mail:
  • Lee H. Schwamm, MD, FAHA, Vice Chairman, Department of Neurology, Director, TeleStroke & Acute Stroke Services, Massachusetts General Hospital, Boston. Phone: (617) 724-1597. Fax: (617) 724-6834. E-mail: