From the Research
The RELAXED trial for stroke 1-2-3-4 rule is a simplified approach to managing acute ischemic stroke that focuses on four key time-sensitive interventions: recognize stroke symptoms within 1 hour of onset, complete emergency medical evaluation within 2 hours, initiate appropriate treatment within 3 hours, and perform endovascular thrombectomy if indicated within 4 hours. This protocol aims to streamline stroke care by emphasizing rapid recognition and treatment, as "time is brain" - approximately 1.9 million neurons die each minute during an acute stroke. The RELAXED approach simplifies complex stroke protocols into an easy-to-remember timeline that healthcare providers can follow to maximize patient outcomes by reducing door-to-needle and door-to-reperfusion times. Early intervention is critical because the effectiveness of both thrombolysis and thrombectomy decreases significantly with each passing hour after symptom onset, as supported by studies such as the Canadian Alteplase for Stroke Effectiveness Study (CASES) registry 1. Some studies, like the Desmoteplase in Acute Ischemic Stroke Trial (DIAS), have explored the use of thrombolytic agents within extended time windows, up to 9 hours, with promising results in terms of reperfusion and clinical outcome 2. However, the most recent and highest quality evidence suggests that the 3-4.5 hour window for thrombolysis is beneficial, with a trend towards higher rates of symptomatic intracranial hemorrhage and mortality in later time windows 1. Key points to consider in the management of acute ischemic stroke include:
- Rapid recognition of stroke symptoms using the Face, Arm, Speech, Time (FAST) rule
- Prompt completion of emergency medical evaluation
- Initiation of appropriate treatment, including intravenous thrombolysis with alteplase, within 3 hours of symptom onset
- Consideration of endovascular thrombectomy if indicated within 4 hours
- Careful patient selection and monitoring for potential complications, such as symptomatic intracranial hemorrhage. Overall, the RELAXED trial for stroke 1-2-3-4 rule provides a framework for healthcare providers to prioritize timely and effective treatment of acute ischemic stroke, with the goal of improving patient outcomes and reducing morbidity and mortality 3, 1.