The Golden Hour of Stroke
The golden hour of stroke refers to the first 60 minutes after stroke symptom onset, during which treatment has the highest efficacy and lowest side effects, offering the best opportunity for favorable outcomes and reduced mortality. 1, 2
Time Sensitivity of Stroke Treatment
- For every minute delay in treating an ischemic stroke, approximately 1.9 million brain cells die, 13.8 billion synapses are lost, and 12 km of axonal fibers are destroyed 3
- Each hour without treatment results in the brain losing as many neurons as it does in almost 3.6 years of normal aging 3
- Procedures exceeding the golden hour are associated with twice the likelihood of poor outcomes and 40% higher rates of symptomatic intracranial hemorrhage 4
Timeframes in Stroke Care
- The hyperacute period for stroke care is time-sensitive, with specific interventions having individual treatment windows 3:
- Minutes for disabling stroke
- Hours for transient ischemic attack (TIA)
- Generally, the first 24 hours after ischemic and hemorrhagic stroke
- First 48 hours after TIA
Importance of Rapid Treatment
- Treatment within the golden hour leads to excellent outcomes regardless of age and pre-existing comorbidity 1
- Patients treated within the golden hour typically have a median NIHSS score of 0 at discharge 1
- In-hospital mortality is significantly reduced (only 2.7%) for patients treated within the golden hour 1
Phases of Stroke Care
Phase 1 (Emergency/Hyperacute): First 3-24 hours after stroke onset 3
- Includes prehospital care and emergency department protocols
- Focus on identifying stroke symptoms, infarct location, and determining treatment options
Phase 2 (Acute Care): 24-72 hours after stroke onset 3
- Focus on clarifying stroke cause, preventing complications, and preparing for discharge
Barriers to Golden Hour Treatment
- Delayed ambulance transport 2
- Inappropriate triage 2
- Difficulty accessing CT scans 2
- Lack of public awareness about stroke symptoms 5
Strategies to Improve Golden Hour Treatment Rates
- Continuous public awareness campaigns about stroke symptoms 5
- Education of emergency medical service personnel 5
- Use of standardized, validated scales for stroke symptom recognition 5
- Advance notification to receiving hospitals 5
- Streamlined in-hospital processes to reduce door-to-needle time 1
- Consideration of mobile stroke units and telemedicine technologies 5
Beyond the Golden Hour: The Platinum 30 Minutes
- The concept of "platinum half-hour" (first 30 minutes after stroke onset) is emerging as an even more critical timeframe 6
- About 12% of patients in a multicenter trial received treatment within this platinum timeframe 6
- Prehospital initiation of treatment can help achieve this ultra-early intervention window 6
Clinical Implications
- The principal aim of hyperacute stroke care is to diagnose stroke type and execute treatment as rapidly as possible 3
- Treatment decisions should prioritize minimizing the absolute time between symptom onset and reperfusion therapy 3
- Systems of care should be designed to facilitate treatment within the golden hour whenever possible 1, 5