Original article Table 2 Improvement by NIHSS scores 24 h after stroke onset, by the time to treatment: comparison between the present study and NINDS study1 Time to treatment after stroke onset (minutes) 0–90 90–180 0–180 NINDS, National Institute of Neurological Disorders and Stroke. Present study Patients with improvement/treated 0/0 20/52 20/52 % 0 38 38 NINDS study Patients with improvement/treated 87/157 60/155 147/312 % 55 39 47 After 24 h, 20 patients (38%) improved, 27 patients (52%) were in a steady condition and five patients (10%) got worse (table 2). After one week, 30 patients (58%) improved neurologically, 14 patients (27%) were in a steady condition and eight patients (15%) got worse or died. At 3 months, 22 patients (43%) had an mRS of 2 or less (0–2), 29 patients (57%) had an mRS of 3 or greater (3–5) or had died and one patient was lost to follow-up. No complications were observed during intravenous infusion in the ED, except for minor gingival bleeding in a few patients. The 3-month mortality rate was 12%: three patients died within the first week (one from myocardial infarction and two from respiratory failure) and another three within 3 months (one from cerebral haemorrhage 7 days after thrombolysis, one from pulmonary embolism and one from candida sepsis). Control CT/MRI scan revealed cerebral bleedings in 18 patients (within 24 h from rt-PA administration in seven, between 1 and 3 days in five, between 4 and 7 days in three, after 7 days in three). According to the criteria of Fiorelli et al,6 eight patients had haemorrhagic infarctions with small pete- chial haematoma (HI1), five had haemorrhagic infarctions with more confluent petechiae (HI2), two had parenchymal haema- toma less than 30% of the infarcted area, with some mild space- occupying effect (PH1) and three had parenchymal haematoma greater than 30% of the infarcted area with significant space- occupying effect or in a remote area (PH2). The cerebral haemorrhage was symptomatic in two patients (4%). DISCUSSION Stroke accounts for a high proportion of health-resource expenses, which are likely to grow with the population ageing. It is, therefore, important to manage the disease in the most effective way, as European governments are aiming to contain healthcare costs and prioritise cost-effective interventions.7 Thrombolytic therapy can change the clinical course of the patient with acute ischaemic stroke, but the 3-h time window requires an efficient organisation and a large number of evenly distributed SU. The treatment delay is due to the late recognition of stroke and to the small number of SU with uneven distribution in the country, so that many patients cannot be transported to specialised centres with experience in thrombolysis within the restricted time window. A clinical study has already shown that patients with ischaemic stroke can safely be submitted to thrombolytic therapy in the setting of a hospital with experience in the treatment of acute stroke, even without a neuro-intensive care unit.8 Patient selection and the following management have to be coordinated and continuously monitored, however, as both are of paramount importance for the best clinical outcome.9 10 Our study shows that the selection of patients with acute stroke and their treatment with intravenous rt-PA in the ED is a feasible solution to implement thrombolytic therapy, as the outcome and rate of symptomatic haemorrhages are comparable with NINDS data, Emerg Med J 2008;25:403–406. doi:10.1136/emj.2007.053033 provided that: (1) the selection of candidates is based on experienced stroke triage and doctors with experience in stroke management; (2) strict collaboration is established between the ED and stroke team for continuous improvement of stroke care, as recommended by the American Heart Association guidelines;11 (3) the patients are submitted to continuous instrumental and clinical monitoring in the following period of high risk of recurrence and neurological deterioration; (4) national and international guidelines are followed with regard to general management and secondary prevention treatment. This pilot study has some limitations. First, the patients were selected only by stroke team investigators, previously authorised by the Ethical Committee. In the future we plan to instruct all ED doctors in the procedure, so that stroke team alert can be avoided. Second, no patient was treated before 90 minutes. This will be overcome by a larger number of ED doctors with expertise in this treatment, which will reduce symptoms-to-needle time. Third, due to the small number of observations we categorised the outcome in two categories (mRS 0–2 and 3–5), which limits a full comparison with the NINDS study. Our preliminary experience can be geographically expanded by establishing a network between hospitals. In Germany a collaborative project aims to extend the use of rT-PA treatment to non-urban areas through telemedic transport (TEMPiS).12 The telemedic system consists of a digital network that includes a video conference focusing on the clinical examination based on NIHSS and CT/MRI image transfer. Stroke experts may propose the best treatment options and support the adminis- tration of intravenous rt-PA, after they have received this information. On the basis of the results of our study, we propose that thrombolysis is performed in the ED of first level outlying hospitals, with the optional support of a stroke team located in third level hospitals (less numerous and more specialised) through televideo consultation. After the procedure, patients can be moved safely to third level referral hospitals to continue specialised treatment. This ‘‘drip and ship’’ approach will offer an extended and effective treatment of stroke, probably at lower costs than if SU were more numerous and spread over a wide territory. Competing interests: AS has participated in clinical trials sponsored by Boehringer Ingelheim (PROFESS and ECASS 3) and has received conference fees from Boehringer Ingelheim (manufacturer of alteplase) as well as from other drug companies (Servier, Solvay, Pfizer, Merck, Sharp & Dohme, Neopharmed, Guidotti). ACP and LAC received conference fees from Boehringer Ingelheim (manufacturer of alteplase) as well as from other drug companies. Ethics approval: The pilot clinical trial was approved by the local Ethical Committee. REFERENCES 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–7. 2. Schumacher HC, Bateman BT, Boden-Albala B, et al. Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med 2007;50:99–107. 405