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Treatment benefits from revascularization decrease over time, and 1. The new extended time windows should not be interpreted to mean that time to treatment should be slowed in any way. Acute stroke treatment is shifting from a time-based to a tissue-based paradigm as emerging evidence suggests that the speed of stroke progression differs between individuals and beneficial treatment may be offered beyond standard time windows.

Using time as the sole criterion to select patients for thrombolysis and endovascular thrombectomy EVT may lead to missed opportunities for treatment. Endovascular intervention refers to EVT as well as other endovascular procedures such as stenting. Refer to Section 4. Note: Clinical consideration 6 is controversial.

It will be updated as additional evidence becomes available. In the meantime, clinicians involved in acute stroke care should focus on improving patient outcomes while safely reducing door-to-needle and door-to-puncture times. Note: Section 5. Note: For systemic hemorrhage, follow local protocol for management guidance.

Meta-analyses of randomized controlled trials RCTs of intravenous alteplase for acute ischemic stroke have shown the treatment can reduce the risk of disability and death, despite a small risk of serious bleeding. The widest time window for alteplase administration after stroke onset remains imprecisely defined, but currently available data show clear evidence of benefit when given up to 4. There remains a strong inverse relationship between treatment delay and clinical outcome; therefore, eligible patients should be treated as soon as possible.