Extending the lytic window in stroke

Current guidelines recommended providing lytics in acute stroke within 3 hours of symptom onset (guidelines). However, 2 new studies provide evidence for extending that window to 4.5 hours. The first observational study found similar 30 day mortality, 30 day functional status, and 24 hour ICH in patients who recieved lytics in <3 hours compared to those in the 3-4.5 hour window (abstract). The second was a RCT of patients presenting between 3-4.5 hours with acute stroke. The lytic group (compared to placebo) had a slightly higher %  favorable 90 day functional score and non-significantly fewer deaths, but significantly more ICH (OR 1.73) (abstract) As an accompanying editorialist notes, “how long do you have to initiate thrombolytic therapy? The correct answer is 1 minute”, indicating that any delay, however short, is too long (editorial). However, in patients presenting between 3-4.5 hours with acute stroke, evidence suggests they should still be evaluated for lytics, as some of them may benefit.

Danielle Scheurer

Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

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