What is the ideal time frame to get to the hospital after a thrombotic (blood clot) stroke?

Time Window for Hospital Arrival After Thrombotic Stroke

Patients experiencing a thrombotic stroke should arrive at the hospital within 4.5 hours of symptom onset to maximize eligibility for thrombolytic therapy, with earlier arrival (ideally within 3 hours) associated with better outcomes. 1

Critical Time Windows for Stroke Treatment

• Intravenous thrombolytic therapy (alteplase) can be administered up to 4.5 hours from stroke symptom onset, though treatment is most effective when given earlier 1, 2
• The "golden hour" for stroke treatment is within the first 3 hours, when thrombolytic therapy has the highest efficacy and safety profile 1, 2
• Some patients may be eligible for endovascular treatment when highly selected by neurovascular imaging up to 24 hours from symptom onset, but this applies only to specific cases 1

Time-Based Treatment Targets

• Door-to-needle time (time from hospital arrival to treatment) should be less than 60 minutes (upper limit) with a target median of 30 minutes or less 1
• On-scene time with suspected stroke patients should be as short as possible, ideally 20 minutes or less for patients presenting within the 4.5-hour treatment window 1
• The European Stroke Organisation recommends a maximum of 30 minutes to obtain and analyze the CT scan 1

Factors Affecting Hospital Arrival Time

• Delay in presentation beyond 3 hours excludes approximately 73% of ischemic stroke patients from receiving thrombolytic therapy 3
• Common reasons for delay include:
  • Uncertain time of symptom onset (24.2%) 3
  • Patients waiting to see if symptoms would improve (29%) 3
  • Delays caused by transfer from outlying hospitals (8.9%) 3
  • Inaccessibility of treating hospital (5.7%) 3

Impact of Arrival Time on Outcomes

• Patients with more severe neurological deficits tend to present earlier to hospitals but may have worse outcomes due to stroke severity 4
• There is a rising proportion of symptomatic intracranial hemorrhage with later treatment windows 2
• Of patients excluded from thrombolytic therapy because their symptoms were considered too mild or rapidly improving, approximately one-third were left either dependent or dead, highlighting the importance of rapid assessment and treatment 3

Recommendations for Maximizing Treatment Opportunity

• Emergency Medical Services (EMS) should categorize stroke patients as high priority for evaluation, response, and transport 1
• Direct transport protocols should be in place to facilitate transfer of suspected stroke patients to the most appropriate acute care hospital capable of providing thrombolytic therapy 1
• While en route to the hospital, paramedics should notify the emergency department of the incoming stroke patient to activate "Code Stroke" protocols 1
• Patients should be triaged as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases, or Level 1 for those with compromised airway, breathing, or cardiovascular function 1

Strategies to Reduce In-Hospital Delays

• Perform as little as possible after the patient arrives at the emergency room and as much as possible before arrival while the patient is being transported 5
• Implement rapid stroke imaging protocols to reduce delays in obtaining CT scans 6
• Develop efficient protocols for blood pressure control prior to thrombolysis 6
• Improve stroke triage and paging systems to minimize delays 6

Remember that "time is brain" - for every minute delay in treating a stroke, an estimated 1.9 million neurons are lost, emphasizing the critical importance of rapid hospital arrival and treatment 1.