There comes a time when each of the medical specialties shifts paradigms from the “take two aspirin and call me in the morning” mindset to more aggressive, time-sensitive therapies for their most acute and devastating conditions. For neurologists, the condition was acute ischemic stroke, and the treatment was thrombolysis. In the late 1980s, animal stroke models showed benefit with intravenous thrombolytic therapies when given within 2 to 3 hours, which translated into human studies in the early 1990s.1 Studies showed that alteplase significantly improves the overall odds of a good stroke outcome when delivered within 4·to 5 hours of stroke onset, with earlier treatment associated with bigger proportional benefits.2 The stage was set for the paradigm “time is brain” to be spun into the tapestry we have today.
This tapestry is made of threads representing ways to reduce the time from the onset of a stroke to treatment with cross-stitches that reduce risks and complications. To these ends, spoke and hub models have been created to start therapy immediately at the closest sites, and highly specialized comprehensive stroke centers have been designated for more invasive treatments. Much of what is described is regional system and local protocol based. Clinical scores have been utilized—e.g., the National Institutes of Health Stroke Scale and RACE score,3 Glasgow coma scale, and modified Rankin score—to make sure all components are speaking the same language. In some regions, mobile stroke units have been shown to reduce time to treatment.4
The race to quickening treatment has included public awareness and education for stroke symptoms (e.g., BEFAST)5 and every seemingly minor process piece that could shave off time to treatment. Simple processes such as placing patients in the hall outside the computed tomography scanner instead of rooming them, fast-tracking laboratory tests and intravenous line placement, and telemedicine have been crucial. Imaging is a rate-limiting step in mobilizing different therapies and has taken an even more prominent role with ASPECTS,6 ICH scores,7 and AI-based imaging analysis (e.g., Rapid AI or Viz AI).8
Apart from imaging, many of the crucial decisions to be made depend on the patient’s history, namely, the severity of symptoms, time of onset, and bleeding risk based on concurrent health conditions, medications, recent surgeries or injuries, and vital signs. The article by Kimbrell et al in this issue of Baylor University Medical Center Proceedings9 describes emergency medical services communication with the emergency departments to prepare them for the patient en route with the goal of reducing time to treatment. It will, of course, be necessary to standardize the histories being communicated and their level of accuracy, especially in the world of telemedicine, where history chasing has taken on new realms of detective work, often dependent on emergency services.
—Sadat A. Shamim, MD
Department of Neurology, Baylor University Medial Center, Dallas, Texas, USA
sadat.shamim@bswhealth.org
http://orcid.org/0009-0004-4091-6969
References
- 1.National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group . Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–1587. doi: 10.1056/NEJM199512143332401. [DOI] [PubMed] [Google Scholar]
- 2.Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929–1935. doi: 10.1016/S0140-6736(14)60584-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45(1):87–91. doi: 10.1161/STROKEAHA.113.003071. [DOI] [PubMed] [Google Scholar]
- 4.Navi BB, Audebert HJ, Alexandrov AW, Cadilhac DA, Grotta JC, PRESTO (Prehospital Stroke Treatment Organization) Writing Group . Mobile stroke units: evidence, gaps, and next steps. Stroke. 2022;53(6):2103–2113. doi: 10.1161/STROKEAHA.121.037376. [DOI] [PubMed] [Google Scholar]
- 5.Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA.. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke. 2003;34(1):71–76. doi: 10.1161/01.STR.0000044170.46643.5E. [DOI] [PubMed] [Google Scholar]
- 6.Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol. 2001;22(8):1534–1542. [PMC free article] [PubMed] [Google Scholar]
- 7.Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC.. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–897. doi: 10.1161/01.STR.32.4.891. [DOI] [PubMed] [Google Scholar]
- 8.Hudson A, Sachdev H, Marklein S, Ong K, Flores M. Detection of large vessel occlusion using AI: evaluating RapidAI versus VizAI in detection of LVO on CT angiography in a large consecutive patient series of 1,591 code strokes (DUEL). Presented at: ISC 2025; February 5-7; Los Angeles, CA, Abstract LBP68/.
- 9.Kimbrell J, Shekhar AC, Stebel J, et al. Prehospital notification in acute stroke: a retrospective cohort study. Proc (Bayl Univ Med Cent). 2025;38(5):622–625. doi: 10.1080/08998280.2025.2514984. [DOI] [Google Scholar]