Early intravenous thrombolysis appears to benefit patients with moderate stroke as well as those with mild stroke, although it's not completely clear if the benefit in mild patients is due more to the lower baseline stroke severity. Nevertheless, patients with mild or moderate symptoms should get thrombolytic treatment as early as possible – within 90 minutes of symptom onset and even earlier, Dr. Daniel Strbian and his colleagues reported (doi: 10.1161/STROKEAHA.111.000819). Those with mild symptoms and early treatment were 51% more likely to have excellent three-month outcomes, defined as a modified Rankin Scale (mRS) score of 0, in a secondary analysis of the study, reported Dr. Strbian of Helsinki University Central Hospital, Finland. The study builds on the authors’ previous single-center analysis of ultra-early thrombolytic treatment delivered within 70 minutes of symptom onset, which found significantly improved three-month outcomes in patients with severe stroke. But, they noted, “because not all patients benefit from early IV thrombolysis equally … we aimed to explore, in a large multicenter dataset, whether the extra benefit is distributed equally among predefined stroke severity subgroups of acute ischemic stroke patients.” However, only 6% of the 878 patients in that cohort got the ultra-early treatment. Therefore, the new analysis was expanded to examine outcomes in patients treated within 90 minutes. “This is a relevant time-point, because the number needed to treat doubles from 4.5 to 9 for patients with [treatment initiation of] 91 to 180 minutes, compared with … 90 minutes or less.” The multicenter analysis comprised 6,856 patients treated at four stroke centers; 19% received treatment within 90 minutes of symptom onset. The mean baseline National Institutes of Health Stroke Score was 11; the score was mild in one-third of patients, moderate in one-third, and severe in one-third. Compared with later treatment, treatment within 90 minutes or less for patients with moderate symptoms was significantly associated with excellent three-month outcomes, defined as an mRS score of 0-1 (odds ratio, 1.37). This benefit was not seen in patients with severe or mild symptoms. The lack of benefit for patients with mild symptoms may have been influenced by their less severe pathophysiology at baseline, the authors noted. they conducted a subanalysis, restricting three-month outcomes to the best possible measurement – an mRS of 0. Patients who got the early treatment were 51% more likely to achieve this outcome than were those treated outside the 90-minute window (OR, 1.51). Editor's NoteHere is yet another decent study that strengthens the notion that all patients with sudden onset neurological deficit should be treated urgently, since minutes can correlate with brain (and functional) preservation. I think it is critical for us as educators and leaders in the postacute and long-term care setting to constantly emphasize to our front-line care staff (and patients and families) that when a TIA-like episode occurs, the safest and most prudent course is to call 9-1-1 and get the patient to a stroke center, unless the patient is clearly not a candidate for that kind of treatment.This intervention can have huge quality-of-life implications, but in day-to-day practice these types of symptoms are often ignored. The patient is put to bed, and the call to his or her physician is not answered for a few hours. By then, the window has closed.Please stay vigilant, now that we actually have successful interventions at our disposal. Save those brain cells. They are in short supply for many of us, and shrinking all the time.—Karl Steinberg, MD, CMD, Editor in Chief Here is yet another decent study that strengthens the notion that all patients with sudden onset neurological deficit should be treated urgently, since minutes can correlate with brain (and functional) preservation. I think it is critical for us as educators and leaders in the postacute and long-term care setting to constantly emphasize to our front-line care staff (and patients and families) that when a TIA-like episode occurs, the safest and most prudent course is to call 9-1-1 and get the patient to a stroke center, unless the patient is clearly not a candidate for that kind of treatment. This intervention can have huge quality-of-life implications, but in day-to-day practice these types of symptoms are often ignored. The patient is put to bed, and the call to his or her physician is not answered for a few hours. By then, the window has closed. Please stay vigilant, now that we actually have successful interventions at our disposal. Save those brain cells. They are in short supply for many of us, and shrinking all the time. —Karl Steinberg, MD, CMD, Editor in Chief