Within what time frame after the onset of stroke-like symptoms should hospitalization and inpatient stroke workup be considered?

Time Frame for Hospitalization and Inpatient Stroke Workup After Stroke-Like Symptoms

Patients with stroke-like symptoms should be hospitalized and receive inpatient stroke workup immediately if presenting within 24 hours of symptom onset, with highest priority for those presenting within 4.5 hours when thrombolytic therapy may be administered. 1, 2

Risk Stratification Based on Time from Symptom Onset

HIGHEST Risk (Symptoms within 48 hours)

• Patients with transient, fluctuating, or persistent unilateral weakness (face, arm, and/or leg), language/speech disturbance, or other symptoms suggestive of stroke within the past 48 hours should be immediately sent to an emergency department with capacity for advanced stroke care 1
• Urgent brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA) should be completed as soon as possible within 24 hours 1
• These patients require immediate hospitalization to facilitate possible early deployment of thrombolytic therapy and other medical management if symptoms recur 1

HIGH Risk (Symptoms between 48 hours and 2 weeks)

• Patients presenting between 48 hours and 2 weeks from onset with symptoms of unilateral weakness or language/speech disturbance should receive comprehensive clinical evaluation and investigations by a healthcare professional with stroke expertise as soon as possible 1
• These evaluations should ideally be initiated within 24 hours of first contact with the healthcare system 1

MODERATE Risk (Symptoms between 48 hours and 2 weeks without motor or speech symptoms)

• Patients presenting between 48 hours and 2 weeks with symptoms without unilateral motor weakness or language/speech disturbance (e.g., sensory symptoms, vision loss, ataxia) should receive comprehensive evaluation ideally within two weeks 1

LOWER Risk (Symptoms present for more than 2 weeks)

• Patients presenting more than 2 weeks following suspected TIA or non-disabling stroke should be seen by a neurologist or stroke specialist ideally within one month 1

Critical Time Windows for Acute Treatment

• The "golden hour" for stroke treatment is within the first 3 hours when thrombolytic therapy has the highest efficacy and safety profile 2
• Intravenous thrombolytic therapy can be administered up to 4.5 hours from stroke symptom onset 2
• Selected patients with salvageable brain tissue identified by perfusion imaging may benefit from thrombolytic therapy up to 24 hours after symptom onset, despite an increased risk of symptomatic intracranial hemorrhage 3
• Endovascular treatment may be considered for highly selected patients up to 24 hours from symptom onset based on neurovascular imaging 2, 4

Factors Affecting Hospital Arrival Time

• The type of first medical contact significantly influences hospital arrival time, with patients using emergency services (911) arriving fastest (median 84 minutes) compared to those contacting their personal physician (median 270 minutes) 5
• Time to hospital arrival is longer for strokes occurring at night compared to those occurring during daytime hours 5, 6
• Location at time of stroke affects arrival time, with strokes occurring at home resulting in longer delays than those occurring at work 5
• Severity of symptoms impacts arrival time, with patients experiencing drowsiness, coma, or paralysis of at least one limb more likely to arrive within treatment windows 6

Recommendations for Optimal Stroke Care

• All patients admitted to hospital with acute stroke should be treated on an inpatient stroke unit as soon as possible, ideally within 6 hours of hospital arrival 1
• For patients with their first TIA within the past 24-48 hours, hospitalization should be considered to facilitate possible early intervention if symptoms recur 1
• Multiple and increasingly frequent symptoms ("crescendo TIAs") justify hospitalization rather than expedited ambulatory management 1
• Hospitals and general practitioners should agree on local protocols for referral to specialist assessment clinics for patients with TIA who don't require hospital admission 1

Common Pitfalls to Avoid

• Delaying hospital arrival by contacting primary care physicians instead of emergency services can significantly reduce treatment opportunities 5
• Underestimating the severity of milder symptoms may lead to delayed presentation, yet these patients might benefit most from early treatment 6
• Failing to recognize in-hospital strokes promptly can lead to worse outcomes compared to community-onset strokes 1
• Waiting for symptoms to resolve spontaneously rather than seeking immediate medical attention reduces the chance of receiving time-sensitive treatments 2