Stroke: The Daily PANCE Blueprint
A 68-year-old woman is brought to the emergency department with sudden onset of right-sided weakness and aphasia. The symptoms started 2 hours ago. Her medical history includes hypertension and atrial fibrillation. She is currently on anticoagulation therapy. What is the therapeutic window for using recombinant tissue plasminogen activator (rtPA) in acute ischemic stroke?
A. Within 1.5 hours of symptom onset
B. Within 3 hours of symptom onset
C. Within 4.5 hours of symptom onset
D. Within 6 hours of symptom onset
E. Within 12 hours of symptom onset
Answer and topic summary
The answer is C. Within 4.5 hours of symptom onset
The therapeutic window for administering recombinant tissue plasminogen activator (rtPA) in acute ischemic stroke is within 4.5 hours of symptom onset. This timeframe is based on clinical trials and guidelines that have shown the benefit of rtPA in improving outcomes when administered in this window. Administering rtPA within this period can lead to reperfusion of the ischemic brain tissue, potentially reducing the extent of the stroke and improving functional outcomes. However, it’s crucial to first exclude intracranial hemorrhage through imaging studies like a CT scan before administration.
Two updates worth knowing: tenecteplase (a single IV bolus) is now an accepted alternative to alteplase with similar outcomes, and selected patients 4.5 to 9 hours from last known well (or with a wake-up stroke) may still receive IV thrombolysis when perfusion imaging shows salvageable brain tissue. A large-vessel occlusion can be treated with mechanical thrombectomy up to 24 hours with appropriate imaging. Because this patient takes an anticoagulant, check before treating: thrombolysis is withheld if her INR is above 1.7 or she took a direct oral anticoagulant within the last 48 hours.
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Neurology ⇒ ⇒
Also covered as part of the Emergency Medicine EOR topic lists
