Introduction

Stroke defines an acute vascular event in the

brain and is a leading cause of death and

disability. Ischemic stroke results from decreased

blood flow to a portion of the brain with

consequent cell death. Hemorrhagic stroke, on

the other hand, is a result of bleeding into the

brain. Ischemic stroke is far more common and is

potentially treatable with thrombolytic therapy.

While effective, the wide application of this

therapy has been hampered by restrictive selection

criteria based on time since onset of symptoms.

Successful treatment requires a system capable of

rapidly identifying and evaluating prospective

candidates. In this context, use of community

education, specific ED protocols and designated

treatment centers may demonstrate some

advantages. Evidence is emerging that patient

selection by time since stroke onset, imaging

characteristics, and intra-arterial treatment may

increase the probability of recanalisation of

occluded vessels. Normalization of serum glucose,

acute blood pressure management and surgical

extraction of intracerebral clot may be of benefit

in some circumstances. 

The purpose of this report is to systematically

review the available literature in the field of acute

stroke evaluation and treatment. The task of the

University of Ottawa Evidence-based Practice

Center (UO-EPC) involved the following three

areas: (1) What interventions in acute stroke (<24

hours from onset) are effective in reducing

morbidity and mortality? (2) How do safety and

effectiveness of these interventions vary by timing

in relation to onset of symptoms? (3) What is the

evidence that specific systems of care improve

outcomes of acute stroke?

Methods 

The databases searched were MEDLINE®

(1966 to April Week 4 2004), EMBASE (last 6

months) and CINAHL® (1982 to April Week 5

2004) using the OVID interface. Also searched

were the Stroke Trials Directory, the Cochrane

Stroke Group Registry, conference proceedings

from the 28th International Stroke Conference

2003 (Stroke, February 2004) and the American

Academy of Neurology Annual Meeting

(published in Neurology). The Effective Practices

and Organization of Care (EPOC) registry was

searched by the Cochrane review group.

All results of searches for evidence were

provided to two reviewers for assessment. All

studies were screened by both reviewers by

reviewing the bibliographic records, and when

meeting inclusion criteria, the subsequent full-text

of the record. If the reviewers did not agree in

finding at least one unequivocal reason for

excluding the study, it was entered into the next

phase of the review. The reasons for exclusion

were noted using a modified QUOROM format.

Two reviewers independently abstracted the

contents of each included study using an

electronic Data Abstraction form developed

Evidence Report/Technology Assessment

Number 127

Acute Stroke: Evaluation and Treatment

Summary

Authors: Sharma M, Clark H, Armour T, Stotts G, Coté R, Hill MD, Demchuck AM, Moher D,

Garritty C, Yazdi F, Lumely-Leger K, Murdock M, Sampson M, Barrowman N, Lewin G

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality Evidence-Based

Practice
2

especially for this review. Data abstracted included the study

and population characteristics, intervention characteristics and

relevant outcomes of included studies.

Attempts were made to minimize and, where not possible,

explain statistical and clinical heterogeneity. Pooled estimates

were only calculated if clinically and statistically appropriate. In

situations where it was felt that quantitative synthesis could not

be performed, a qualitative narrative synthesis was conducted.

Results 

Intervention A 

Does surgery impact the outcome in patients with acute

intracerebral hematoma? Twenty-three studies were identified

by our search. Meta-analysis was conducted on four studies.

The four trials had a total of 246 subjects. The pooled estimate

favored treatment; however, the confidence interval crossed the

null (OR=0.24 [0.02, 3.03]). A meta-analysis for the outcome

of death produced similar results (OR=0.62 [0.34, 1.13]). The

meta-analysis was repeated including the study published after

the period included in the search strategy. This study had

significantly greater numbers than the other included studies;

however, the conclusion of the meta-analysis was not altered.

Once again, the odds ratio for death had a point estimate

favoring treatment; however, the confidence interval clearly

crossed the null (OR=0.81 [0.54, 1.22]). Moderate

heterogeneity was noted. 

Intervention B 

Does antihypertensive treatment reduce stroke-related

mortality and disability in patients with acute intracerebral

hemorrhage (ICH)? Six studies were identified that

investigated antihypertensive therapy for ICH. Four of these

were non comparative case series and thus were excluded from

our review. Two unique studies met eligibility criteria and were

pre- and post-designs. Neither study commented on outcomes

of death or disability. One suggested that cerebral perfusion

pressure was not altered with antihypertensive therapy.

Intervention C

Does intra-arterial (IA) thrombolysis reduce strokerelated mortality and disability in adults with acute

ischemic stroke? Of the 37 studies identified by the search

strategy, five unique publications met criteria for inclusion. Two

studies could be combined with the pooled estimates for death

and disability and death favoring treatment with a confidence

interval which crossed the null in both cases: death and

disability (OR=0.55 [0.29, 1.16]), and death (OR=0.78 [0.42,

1.47]). Thus, while the pooled estimates for these outcomes are

not statistically significant the possibility of substantial benefit

from intra-arterial therapy cannot be excluded. A pooled

estimate of the impact on disability alone could not be

obtained from the available data. A single study1 suggests an

absolute improvement in the proportion of subjects with a

mRS score < or = 2 of 15 percent. The odds ratio for this

outcome was 2.13 (1.02, 4.42).

Intervention D 

Does treatment to normalize blood glucose levels reduce

stroke-related mortality and disability in adults with acute

stroke? No studies were identified which specifically addressed

this question. Two unique publications demonstrated the

feasibility of reduction in serum glucose levels but were not

designed to measure clinical outcome.

Intervention E 

Does mechanical clot disruption reduce stroke-related

mortality and disability in adults with acute ischemic

stroke? Ten studies were identified by the search criteria and

one, which fell outside the search dates, was provided by an

expert. Of these, two unique RCTs met the criteria for

inclusion. Both evaluated the effect of ultrasound enhanced

thrombolysis in middle cerebral artery (MCA) occlusion.

Primary end points differed but the treatment effect in both

studies favored intervention.

Intervention F

Is the effectiveness and safety of thrombolytic therapy

for adults with acute ischemic stroke affected by time from

onset to treatment? No single study has attempted to

investigate the impact of timing on thrombolysis treatment

outcome. However, five unique publications examining

treatment outcomes across relevant time windows were

included.2

Studies examining enrollment of patients 3 to 5 hours after

stroke onset and 0 to 6 hours after onset did not show

treatment benefit.2,3 Reanalysis of the NINDS trial data4

suggested improved functional outcome for the 0-90 minute

stratum as compared with the 91-180 minute interval. A

patient level meta-analysis of six trials of tPA treatment for

ischemic stroke with treatment windows between 0 and 6
hours was identified which examined the relationship between

onset to treatment time and outcome.5 A clear association was

found between onset to treatment time and outcome. The odds

ratio for favorable outcome with tPA treatment in the 0 to 90

minute interval was 2.81 (95% CI 1.75-4.50). This decreased

to 1.15 (0.90-1.47) in the 271 to 360 minute interval. No

increase in mortality was noted until the 271-360 minute

interval.

Intervention G 

Do pretreatment CT scoring systems affect the safety

and efficacy of thrombolytic therapy for acute ischemic

stroke? Two unique studies were included in this analysis.6

Prospective evaluation of CT scoring systems was not available,

and both included studies are evaluations of CTs conducted

during the course of prospective trials of thrombolysis in stroke.

Analysis of CT scans from patients in the NINDS trial

demonstrates that while early infarct changes are common, they

correlate poorly with outcome.6 A weak association between

early CT changes and outcome was noted in the PROACT 2

trial.7

Intervention H 

Do pretreatment MRI scoring systems affect the safety

and efficacy of thrombolytic therapy for acute ischemic

stroke? Six studies were identified that addressed the

effectiveness of an MRI scoring system for ischemic stroke.

One multiple prospective cohort study8 and one single

prospective cohort study,9 published in 2002 and 2003, were

included in our review. Three non comparative case series

reports10-12 and one case study were excluded for level of

evidence.13 Neither of the included studies used MRI measures

prospectively to make decisions on thrombolysis. Both,

however, provided correlations with surrogate measures which

may be useful in clinical decision making. Recanalisation and

initial diffusion-weighted imaging (DWI) lesions were found to

correlate with clinical outcome and infarct volume at 60 days.

In addition, in patients treated with intravenous tPA, time to

peak was correlated with recanalisation at day 1. Thirteen of 15

patients (93 percent) whose baseline time-to-peak was less than

or equal to 36.9 milliseconds recanalized within the first day

versus 5 of 15 patients (35.7 percent) whose time-to-peak was

greater than 36.9 milliseconds.9 Suarez and colleagues8 reported

a single-center cohort in which the presence of cortical infarct

on MRI was used to select patients for IA treatment following

IV treatment. MR imaging added 17 minutes to the treatment

protocol and thus was felt to be feasible but due to the absence

of a comparison group no comment can be made about

marginal effectiveness over current treatment protocols. 

Intervention I 

Do CT perfusion/angiography affect the safety and

efficacy of thrombolytic therapy for acute ischemic stroke?

Three studies (four publications) examining CT perfusion/

angiography for ischemic stroke were identified.14-17 One

potentially relevant trial14,15 was published in abstract form and

the authors were contacted to determine if subsequent articles

were published. These were excluded following full text

screening. Study design could not be determined in two

publications and were excluded for level of evidence.18,19 One

single retrospective cohort study16 and one case-control study,17

published in 2001 and 2004, respectively, were included in our

review. 

The hyperdense MCA sign was evaluated in a small cohort

of patients treated with either IV or IA Thrombolysis.17 The

hyperdense MCA sign was associated with a greater probability

of recovery with IA than intravenous treatment (37 percent

versus 13 percent). This observational data17 suggests that this

sign may be used as a tool to triage patients between

intravenous and IA treatment. There is a higher probability that

proximal large vessel occlusion as reflected by this sign may be

associated with worse outcomes intravenously. This observation

will require testing in a prospective study. 

Kilpatrick and colleagues16 reported on a retrospective cohort

of 51 patients from a single center between 1997 and 2000. A

CT angiogram showing patent vessels was associated with a rate

of infarct of 7 percent (1/14 patients) while CT angiogram

showing occlusion had an infarct rate of 60 percent (6/10)

(p=0.008). 

Intervention J 

Are community education programs effective in

reducing stroke-related disability and mortality? One

controlled clinical trial,20 six before-after studies,21-26 and one

study for which the study design could not be determined,27

investigated the use of community education programs for

acute stroke. Subsequently, seven studies were excluded for level

of evidence.21-27 Only one study20 was included for our review.

This study was a controlled clinical trial and was published in

2003.

3
4

Morgenstern et al.20 reported on the third phase of the TLL

Temple Foundation Stroke Project. Target behaviors of lay

community (the “at-risk group”), EMS, ED physicians,

neurologists, and community primary care providers were

identified, and educational and infrastructure changes were

initiated. A portion of the multilevel intervention public service

announcements were created using local role models, volunteers

were trained to take the message to community groups, and

educational pamphlets were distributed.

Intervention K 

Are designated centers effective in reducing strokerelated disability and mortality? It has been hypothesized

that to increase utilization of thrombolytics, a dedicated stroke

center strategy should be developed.28 No studies meeting

eligibility criteria for investigating the use of designated centers

as defined by the Brain Attack Coalition were identified by our

searches.28 The studies we included were felt to most closely

resemble the model of a designated stroke center as defined by

the Brain Attack Coalition and detailed by Alberts et al.28 in

their recommendations for the establishment of primary stroke

centers. Both studies were single prospective cohort designs and

were published between 2000 and 2003.

Hill et al.29 reported on building a “brain attack” team to

administer thrombolytic therapy to patients with acute stroke

and on their initial experience with IV-administered

thrombolytics. A complex system of interventions involving all

levels of the system involved in acute stroke care was

reorganized. Over the course of the study period improvements

in certain parameters were noted. Overall, symptom onset to

treatment time was significantly decreased from a mean of

167.8 minutes to 147.4 minutes.29

Lattimore and colleagues reported on a similar process of

designation and implementation of processes to enhance

thrombolysis. An increase in the proportion of ischemic stroke

treated with tPA from 1.5 percent to 10.5 percent was noted.30

Intervention L

Are ED protocols for the management of acute stroke

effective in reducing disability and mortality? Our search

identified one case-control study,31 two single prospective

cohort studies,32,33 two single retrospective cohort studies,34,35

two non-comparative case series studies,36,37 and two studies

whose design could not be determined.38,39 The case-control and

non-comparative studies were excluded for level of evidence.

Four studies, published between 1999 and 2003, examining the

effect of ED protocols for management of acute stroke met our

eligibility criteria and were included in our final analyses.32-35

Smith et al.34 reported on the establishment of ED

procedures and training established for the purposes of

thrombolytic treatment. The program relied on ED physicians,

with neurology consultation, as primarily responsible for

treatment. Treatment times in this model compared favorably

with those in models involving comprehensive stroke team

response. A similar effort is reported by Akins.35 Similar

treatment times were achieved when ED physicians treated as

compared to consulting neurologists. The rate of protocol

violations was initially higher in the ED group (30 percent

versus 5 percent) than the neurologist group but was reduced

by staff education. Jahnke et al.33 described a comprehensive

stroke pathway implemented in the ED. Following this

intervention the stroke pathway was initiated in 97 percent of

patients as opposed to 40 percent prior. The door to needle

time decreased from a mean of 111 minutes to 77 minutes.

Discussion

Currently, available data do not support a role for surgery in

the treatment of acute intracerebral hemorrhage. Results,

however, do not preclude benefit from surgery which involves

modalities other than those studied in the acute trials (e.g.,

minimally invasive technologies) or treatment of hemispheric

hematoma at very early timeframes. Further, the available

literature did not comment on cerebellar hematoma and thus

this analysis does not apply to infratentorial hemorrhage.

In spite of potential importance, availability of therapy and

ease of administration of antihypertensive agents, very little

data exists to suggest that their use is of benefit (or results in

harm) in the setting of acute ICH. A similar situation exists

regarding glucose management for acute ischemic stroke.

Further studies are required in both these areas.

IV thrombolysis with tPA is effective and efficacious for

acute ischemic stroke within 3 hours of symptom onset. The

effectiveness is strongly linked to time since onset of symptoms

with shorter times demonstrating significantly better outcomes.

Patient level meta-analysis suggests that treatment may be

effective up to 270 minutes with treatment increasing the odds

of death beyond 270 minutes. Further work is needed to define

the risks and benefits of treatment outside the 3 hour window

prior to advocating widespread use in these patients. Intraarterial therapy remains an option for a subgroup of patients

with large vessel occlusions principally in the middle cerebral
artery distribution. The evidence for this intervention, however,

remains less robust than for IV therapy. Limited data is

available regarding patient characteristics predicting outcome.

The system changes required to ensure prompt delivery of

appropriate therapy are complex and operate on multiple levels.

In spite of their critical role, little data exists regarding the

efficacy of these interventions and, in particular, the relative

efficacy of various components with regard to patient

outcomes. 

Ultrasound for enhancement of thrombolysis in the setting

of MCA occlusion has suggested efficacy in two studies and a

definitive trial to demonstrate the benefit and risks is required.

CT and MR imaging for patient selection and prediction of

outcome in thrombolysis has yet to be prospectively evaluated.

The two included CT studies6,7 differ in onset to evaluation

time with only a weak correlation between CT changes and

outcome seen in the trial enrolling patients from 0-6 hours.

Neither study quantified CT changes. The Alberta Stroke

Program Early CT Score (ASPECTS) score is an easily

quantifiable scoring system for early infarct changes.40

Retrospective evaluation of the ASPECTS score suggests that

values below 7 correlate with poorer outcomes. As CT is widely

available, this system deserves further exploration. Additional

information relevant to treatment decisions may be provided by

CT angiography. Occlusion of proximal vessels is associated

with higher rates of infarction and thus may influence

treatment modalities. 

MRI DWI lesions correlate with the presence of infarcts in

small cohorts of patients and time to peak measures on early

scans may correlate with recanalization after IV tPA treatment.

These findings require reproduction and further evaluation.

The multiplanar abilities and potential for acquisition of

multiple parameters are potentially attractive features of this

modality and may assist in selecting patients with a greater ratio

of benefit to harm in intravenous and intra-arterial treatment

paradigms.

The narrow time window for thrombolysis in acute stroke as

well as the relationship between time to treatment and outcome

has led to the exploration of a number of strategies for

optimization of outcomes. Community education programs

regarding the symptoms of stroke have not been independently

evaluated but rather studied in the context of more

comprehensive system changes. Thus, it is unclear if these

programs are effective in improving patient outcomes. Further

exploration is also required regarding the content and targeting

of such programs. Descriptions of designated treatment centers

have shown the feasibility of this approach but an evaluation of

published criteria for and marginal effectiveness of such

designations remains to be performed. 

Availability of the Full Report

The full evidence report from which this summary was taken

was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the University of Ottawa Evidence-based

Practice Center, under Contract No. 290-02-0021. It is

expected to be available in July 2005. At that time printed

copies may be obtained free of charge from the AHRQ

Clearinghouse by calling 800-358-9295. Requesters should ask

for Evidence Report/Technology Assessment No. 127, Acute

Stroke: Evaluation and Treatment. In addition, Internet users

will be able to access the report and this summary online

through AHRQ's Web site at www.ahrq.gov. 

Suggested Citation

Sharma M, Clark H, Armour T, Stotts G, Coté R, Hill MD,

Demchuck AM, Moher D, Garritty C, Yazdi F, Lumely-Leger

K, Murdock M, Sampson M, Barrowman N, Lewin G. Acute

Stroke: Evaluation and Treatment. Summary, Evidence

Report/Technology Assessment No. 127. (Prepared by the

University of Ottawa Evidence-based Practice Center under

Contract No. 290-02-0021.) AHRQ Publication No. 05-E023-

1. Rockville, MD: Agency for Healthcare Research and Quality.

July 2005.

References

1. Furlan A, Higashida R, Wechsler L et al. Intra-arterial prourokinase

for acute ischemic stroke. The PROACT II study: a randomized

controlled trial. Prolyse in Acute Cerebral Thromboembolism.[see

comment]. JAMA 1999; 282(21):2003-11.

2. Clark WM, Albers GW, Madden KP, et al. The rtPA (alteplase) 0- to

6-hour acute stroke trial, part A (A0276g) : results of a double-blind,

placebo-controlled, multicenter study. Thromblytic therapy in acute

ischemic stroke study investigators. Stroke 2000; 31(4):811-6.

3. Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type

plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after

symptom onset. The ATLANTIS Study: a randomized controlled

trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in

Ischemic Stroke.[see comment]. JAMA 1999; 282(21):2019-26.

4. Marler J, Tilley BC, Lu Y, et al. Early stroke treatment associated with

better outcome: the NINDS rt-PA stroke study. Neurology 2000;

55(11):1649-55.

5
5. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with

early stroke treatment: pooled analysis of ATLANTIS, ECASS, and

NINDS rt-PA stroke trials. Lancet 2004; 363(9411):768-74.

6. Patel SC, Levine SR, Tilley BC, et al. Lack of clinical significance of

early ischemic changes on computed tomography in acute stroke.[see

comment]. JAMA 2001; 286(22):2830-8.

7. Roberts HC, Dillon WP, Furlan AJ, et al. Computed tomographic

findings in patients undergoing intra-arterial thrombolysis for acute

ischemic stroke due to middle cerebral artery occlusion: results from

the PROACT II trial.[see comment]. Stroke 2002; 33(6):1557-65.

8. Suarez JI, Zaidat OO, Sunshine JL, et al. Endovascular administration

after intravenous infusion of thrombolytic agents for the treatment of

patients with acute ischemic strokes. Neurosurgery 2002; 50(2):251-9.

9. Hermier M, Nighoghossian N, Adeleine P, et al. Early magnetic

resonance imaging prediction of arterial recanalization and late infarct

volume in acute carotid artery stroke. J Cereb Blood Flow Metab

2003; 23(2):240-8.

10. Chalela JA, Kang DW, Luby M, et al. Early magnetic resonance

imaging findings in patients receiving tissue plasminogen activator

predict outcome: Insights into the pathophysiology of acute stroke in

the thrombolysis era. Ann Neurol 2004; 55(1):105-12.

11. Neumann-Haefelin T, Du M, Fiebach DR, et al. Effect of incomplete

(spontaneous and postthrombolytic) recanalization after middle

cerebral artery occlusion: a magnetic resonance imaging study. Stroke

2004; 35(1):109-14.

12. Tong DC, Adami A, Moseley ME, et al. Prediction of hemorrhagic

transformation following acute stroke: role of diffusion- and

perfusion-weighted magnetic resonance imaging.[see comment]. Arch

Neurol 2001; 58(4):587-93.

13. O'Rourke F, Akhtar N, Emery D, et al. Use of MRI in the

identification and treatment of early ischemic stroke lesions. CMAJ

2004; 170(3):335-6.

14. Kim YB, Lee KH, Lee SJ, et al. Safety and efficacy of intravenous

thrombolysis with tissue plasminogen activator using triphasic

perfusion CT in acute ischemic stroke. Cerebrovasc Dis 2000;

10(Suppl 2):78.

15. Lee K, Lee S, Kim Y, et al. Usefulness of triphasic perfusion CT for

intravenous thrombolysis with tissue plasminogen activator in acute

ischemic stroke. Stroke 2000; 31(11):2889.

16. Kilpatrick MM, Yonas H, Goldstein S, et al. CT-based assessment of

acute stroke: CT, CT angiography, and xenon-enhanced CT cerebral

blood flow.[see comment]. Stroke 2001; 32(11):2543-9.

17. Agarwal PK. Hyperdense middle cerebral artery sign: can it be used to

select intra-arterial versus intravenous thrombolysis in acute ischemic

stroke? Cerebrovasc Dis 2004; 17(2-3):182-90.

18. Koenig M, Kraus M, Theek C, et al. Quantitative assessment of the

ischemic brain by means of perfusion-related parameters derived from

perfusion CT. Stroke 2001; 32(2):431-7.

19. Lee KH, Lee SJ, Cho SJ, et al. Usefulness of triphasic perfusion

computed tomography for intravenous thrombolysis with tissue-type

plasminogen activator in acute ischemic stroke. Arch Neurol 2000;

57(7):1000-8.

20. Morgenstern LB, Bartholomew LK, Grotta JC, et al. Sustained benefit

of a community and professional intervention to increase acute stroke

therapy. Arch Intern Med 2003; 163(18):2198-202.

21. Barsan WG, Brott TG, Broderick JP, et al. Urgent therapy for acute

stroke. Effects of a stroke trial on untreated patients. Stroke 1994;

25(11):2132-7.

22. Smith WS, Corry MD, Fazackerley J, et al. Improved paramedic

sensitivity in identifying stroke victims in the prehospital setting.

Prehosp Emerg Care 1999; 3(3):207-10.

23. Becker K, Fruin M, Gooding T, et al. Community-based education

improves stroke knowledge. Cerebrovasc Dis 2001; 11(1):34-43.

24. Morgenstern LB, King M, Staub L, et al. Community and

professional intervention to increase FDA-approved acute stroke

therapy: final main results of the TLL Temple Foundation stroke

project. Neurology 2001; 56(Suppl 3):A77.

25. Weinhardt J, Parker C. Developing a patient education video as a tool

to case manage patients who have had strokes. Nurs Case Manag

1999; 4(4):198-200.

26. Alberts MJ, Perry A, Dawson DV, et al. Effects of public and

professional education on reducing the delay in presentation and

referral of stroke patients. Stroke 1992; 23(3):352-6.

27. Williams JE, Rosamond WD, Morris DL. Stroke symptom

attribution and time to emergency department arrival: the delay in

accessing stroke healthcare study. Acad Emerg Med 2000; 7(1):93-6.

28. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for

the establishment of primary stroke centers. Brain Attack Coalition.

JAMA 2000; 283(23):3102-9.

29. Hill MD, Barber PA, Demchuk AM, et al. Building a "brain attack"

team to administer thrombolytic therapy for acute ischemic stroke.

CMAJ 2000; 162(11):1589-93.

30. Lattimore SU, Chalela J, Davis L, et al. Impact of establishing a

primary stroke center at a community hospital on the use of

thrombolytic therapy: the NINDS Suburban Hospital Stroke Center

experience. Stroke 2003; 34(6):e55-e57.

31. Figueira FF. Stroke study group. Preliminary results. Early intensive

care improves functional outcome. Arq Neuropsiquiatr 1994;

52(3):330-8.

32. Lin CS, Tsai J, Woo P, et al. Prehospital delay and emergency

department management of ischemic stroke patients in Taiwan,

R.O.C. Prehosp Emerg Care 1999; 3(3):194-200.

33. Jahnke HK, Zadrozny D, Garrity T, et al. Stroke teams and acute

stroke pathways: one emergency department's two-year experience. J

Emerg Nurs 2003; 29(2):133-9.

34. Smith RW, Scott PA, Grant RJ, et al. Emergency physician treatment

of acute stroke with recombinant tissue plasminogen activator: a

retrospective analysis. Acad Emerg Med 1999; 6(6):618-25.

35. Akins PT, Delemos C, Wentworth D, et al. Can emergency

department physicians safely and effectively initiate thrombolysis for

acute ischemic stroke? Neurology 2000; 55(12):1801-5.

36. Wester P, Radberg J, Lundgren B, et al. Factors associated with

delayed admission to hospital and in-hospital delays in acute stroke

and TIA: a prospective, multicenter study. Seek-Medical-Attention-inTime Study Group. Stroke 1999; 30(1):40-8.

6
37. Moulin T, Sablot D, Vidry E, et al. Impact of emergency room

neurologists on patient management and outcome. Eur Neurol 2003;

50(4):207-14.

38. Pearson BJ, Bath PM, Spence JD. Hypertension in patients presenting

with stroke. [Review]. Current Hypertension Reports 2000; 2(6):551-

7.

39. Tilley BC, Lyden PD, Brott TG, et al. Total quality improvement

method for reduction of delays between emergency department

admission and treatment of acute ischemic stroke. The National

Institute of Neurological Disorders and Stroke rt-PA Stroke Study

Group. Arch Neurol 1997; 54(12):1466-74.

40. 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):1534-42.

7
www.ahrq.gov

AHRQ Pub. No. 05-E023-1

July 2005

ISSN 1530-440X