Prehospital thrombolysis for acute ischemic stroke: the hope of a paradigm shift?

Intravenous thrombolysis, the only licensed treatment for acute ischemic stroke, can be started up to 4.5 hours after symptoms' onset, after ruling out an intracerebral hemorrhage. However, the sooner thrombolysis is given, the higher the probability of a functional recovery. While acute stroke patients are currently taken to the hospital to undergo brain imaging, two distinct german teams have evaluated prehospital thrombolysis, using a CT scanner-equipped ambulance. The Homburg team showed in a randomized controlled trial that, compared with regular care, the implementation of the specialized ambulance resulted in a 41 minutes absolute reduction of the median alarm-to-treatement decision time, and a 80 minutes absolute reduction of the onset-to-thrombolysis time (OTT). The undergoing PHANTOM-S study aims at assessing the implementation of a specialized ambulance to reduce the alarm-to-thrombolysis time in Berlin. The pilot, non-randomized phase of this study suggested a 34 minutes absolute reduction of the median alarm-to- thrombolysis time, and a 37 minutes absolute reduction of the median OTT. Further studies are warranted to confirm these preliminary findings and determine if prehospital thrombolysis can lead to a paradigm shift in acute stroke management.