Acute Neurovascular Syndromes: Hurry Up, Please, It’s Time1

“It isn’t that they can’t see the solution. It is that they can’t see the problem.” 2 Less than 20 years ago, the most common cited reason for the admission of a patient with stroke to hospital was for nursing or general nonmedical care.3 Admission to make or confirm the diagnosis or for medical treatment were mentioned less than half as often. In the same study, the most common reasons for patients remaining in the community were that they had suffered a minor stroke or services were available in the community for assessment and work-up. The evidence surrounding the benefit of aspirin in acute stroke, the reduction of death and dependence with admission of patients to dedicated stroke units, and perhaps most controversially, the demonstration of the efficacy of thrombolysis, by either intravenous or intra-arterial routes, in reducing disability following acute ischemic stroke had yet to appear.4,5 This article does not seek to re-examine the debate surrounding the use of thrombolysis in acute ischemic stroke. This has been explored at length elsewhere.6–8 The aim of this article is to explore the new perspective on the treatment of hyperacute cerebral ischemia that has arisen because of the increasing use of tissue plasminogen activator (tPA), in particular the influence of time. The organization of acute stroke services is now required to be time sensitive to ensure that the maximum number of patients eligible for thrombolysis have the greatest chance of a good neurological outcome as possible.9 As a result, patients are presenting sooner, emergency services are prioritizing the transport of these patients to hospital, and physicians are assessing these patients more quickly.10 However, thrombolysis in acute cerebral ischemia is not a panacea, just as it has not been in acute coronary syndromes. Rather, it has provided a …