Original article Neurological Disorders and Stroke (NINDS) trial.1 The most common reasons against rt-PA treatment were age greater than 80 years, time window greater than 3 h, unclear onset of symptoms, rapidly improving symptoms, mild stroke (National Institutes of Health Stroke Scale (NIHSS) score (4), severe stroke (NIHSS score >25) and pretreatment with anticoagu- lants. Pretreatment with aspirin or other antiplatelet agents was not an exclusion criterion. Special attention was paid to exclude patients with uncontrolled hypertension, but in a few patients blood pressure control was obtained with one or two small intravenous labetalol bolus injection(s) before thrombolysis.1 If the patient fulfilled the inclusion/exclusion criteria, ED doctors contacted the stroke team on a convenience basis, mostly between 08:00 and 20:00 hours during weekdays, with a single page, located family members, urgently obtained a computed tomography (CT) scan and laboratory tests. One stroke team investigator, previously authorised by the local Ethical Committee, convened for clinical assessment, to verify inclusion/exclusion criteria and to obtain a written informed consent from the patient or a close relative, while the CT scan was performed. Neurological deficit on admission was measured by the NIHSS. rt-PA (Actilyse, Boehringer Ingelheim, Germany) was admi- nistered intravenously at a dose of 0.9 mg/kg body weight (maximum dose 90 mg), with 10% given as a bolus and the remaining 90% as a constant infusion over one hour under direct stroke team supervision in the ED. The patients had to be treated within 3 h from symptom onset. After thrombolytic infusion, the patients were transferred to a semi-intensive SU, under supervision of the same stroke team investigator, to be followed up for the treatment of complica- tions and rehabilitation. Clinical monitoring was performed every 2 h for the first 24 h. Blood pressure, heart rate and, when necessary, oxygen saturation were non-invasively monitored up to 72 h after stroke or longer, if necessary. A follow-up CT scan was performed 24 h after thrombolysis in all patients and whenever the neurological condition worsened. Further CT or magnetic resonance imaging (MRI) studies were left to the discretion of the treating doctor. Neither heparin, aspirin nor other antiplatelet agents were given for 24 h after thrombolysis. Antihypertensive therapy was given according to the American Heart Association guidelines4 and our previous report.5 Rehabilitation therapy was started within 48 h after stroke onset. Table 1 Clinical characteristics of patients enrolled in the present study, in comparison with the NINDS study1 Present study 52 (42) 66 (12) 13 (5–23) 11 39 27 23 147 (22) 77 (13) 130 (59) 3 (6) 2 (4) NINDS study 312 (42) 67 (10) 14 (1–37) 19 35 42 3 155 (22) 85 (12) 149 (76) 16 (5) 20 (6,4) Number (% female) Age, years (SD) NIHSS score (range) Stroke subtypes (%) Small-vessel occlusive Cardioembolic Large-vessel occlusive Other SBP, mm Hg (SD) DBP, mm Hg (SD) Glucose, mg/dl (SD) Mortality within 7 days (%) Symptomatic haemorrhage (%) 404 DBP, diastolic blood pressure; NIHSS, National Institutes of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and Stroke; SBP, systolic blood pressure. Early neurological improvement was defined as a decrease of 4 or more points in the NIHSS score from baseline, or complete resolution of the neurological deficit after 24 h. Early neurolo- gical deterioration was defined as an increase of 4 or more points in the NIHSS score in the same time interval. Telephone or clinic follow-up data were obtained from the patients and/or caregiver 3 months after treatment. Outcome was assessed by modified Rankin scale (mRS), 3-month fatality rate and symptomatic (fatal and non-fatal) intracranial hae- morrhage (SICH). A good outcome was defined as an mRS score from 0 to 2, a poor outcome as death or an mRS score from 3 to 5 (death or dependence). Cerebral bleedings were categorised according to the criteria published by Fiorelli et al6 for the European Cooperative Acute Stroke Study I (ECASS I) cohort: haemorrhagic infarctions with small petechial haematoma (HI1); haemorrhagic infarctions with more confluent petechiae (HI2); parenchymal haematoma less than 30% of the infarcted area with some mild space- occupying effect (PH1); parenchymal haematoma greater than 30% of the infarcted area with significant space-occupying effect or clot remote from the infarcted area (PH2). SICH was defined as any CT/MRI-documented haemorrhage, either within the infarcted area or in a remote area, concomitant with an increase of 4 or more points in the NIHSS score. Fatal SICH was defined as a CT/MRI-detected haemorrhage asso- ciated with in-hospital death. Descriptive statistical analysis was performed with SPSS version 13.0. Continuous variables are expressed as mean ¡ SD and as median with range for variables with a non-normal distribution, whereas categorical variables are expressed as counts and percentages, to make comparisons with the NINDS results.1 RESULTS During the study period (1 January 2000 to 30 June 2007), all ED consultations for focal neurological deficits were monitored during five randomly selected weeks. The median number of hospital admissions per week during the monitoring period was 16 (six for acute ischaemic stroke, four for intracerebral haemorrhage, two for transient ischaemic attack and four for other diseases). The median ‘‘symptom to door’’ time was 45 minutes (range 15 minutes to 6 h) and the rate of intravenous rt-PA treatment in acute ischaemic stroke was 7%. As patient selection and supervision could be done only by stroke team investigators authorised by the Ethical Committee, the study cohort was enrolled on a convenience basis and 52 patients with ischaemic stroke were treated with intravenous rt-PA. Their clinical characteristics are reported in table 1. They started treatment within 3 h of symptom onset. In this cohort, the mean delay between symptom onset and hospital admission was 39 minutes, from admission to CT 48 minutes and the median door-to-needle time (delay from admission to rt-PA treatment) 58 minutes. Thirty-four patients (65%) were admitted with a moderate (NIHSS score ,15) and 18 (35%) with a serious stroke (NIHSS score 15–23). According to the Oxford Community Stroke Project classification, 15 (29%) were total anterior circulation infarct, 28 (54%) were partial anterior circulation infarct, six (11%) were lacunar infarction and three (6%) were posterior circulation infarct. According to the TOAST classification, the pathogenesis was cardioembolic in 20 (39%), atherosclerotic in 14 (27%), lacunar in six (11%) and from other or unidentified causes in 12 (23%). Emerg Med J 2008;25:403–406. doi:10.1136/emj.2007.053033