transformative impact of a dedicated neuro ED on expediting care, enhancing efciency, and ultimately improving patient out­comes in acute ischemic stroke.

SCs operate from the hub hospital, functioning as a command center equipped with a dedicated smartphone for stroke calls from spoke hospitals. Communication occurs primarily over the phone, with an option for video evaluation, utilizing a shared picture archiving and communication system (PACS) for immediate neu­roimage review. SCs can consult a vascular neurosurgeon and general neurologist directly through a hotline if needed, ensuring swift decision-making and avoiding delays in patient care [23].

In a retrospective study spanning 19months, the neuro ED’s command center received 457 phone calls for patients meeting stroke alert criteria. SCs managed blood pressure, dosed thrombo­lytics, and provided recommendations for advanced neuroimag­ing. They extensively reviewed inclusion and exclusion criteria for IVT with spoke emergency physicians and facilitated transfers for eligible patients. The study reported a 6.25% incidence of symptomatic intracranial hemorrhage (sICH) for patients receiv­ing IV thrombolytics, consistent with the National Institute of Neurological Disorders and Stroke (NINDS) trial [24].

Despite the Food and Drug Administration (FDA) approving thrombolytics for acute ischemic stroke in 1996, their utilization in the United States has not witnessed a commensurate increase. Notably, from 2007 (2.8%) to 2014 (7.7%), the usage of IVT has experienced a modest rise [27]. However, a substantial proportion of eligible patients remains untreated, indicative of an unmet need within the present healthcare landscape. One primary contributing factor to the suboptimal administration of IVT is the constrained time window, requiring patients to present within 4.5 hours of their last known well status to initiate treatment.

on magnetic resonance imaging (MRI) for advanced neuroimag­ing, a resource not ubiquitously available in many emergency departments across the United States. Furthermore, certain medi­cal conditions, such as the presence of pacemakers, spinal stimu­lators, retained foreign bodies, or claustrophobia, preclude the use of MRI in some stroke patients.

Addressing these challenges, the EXTEND trial, published in 2019, investigated the applicability of IVT guided by CT perfu­sion imaging up to 9hours poststroke onset [28]. This trial focused on patients with ischemic stroke who exhibited hypoperfused but salvageable brain regions as detected by automated perfusion imaging. More of the alteplase-treated patients achieved a favor­able outcome (modied Rankin Scale score 0–1) compared to the control group, with rates of symptomatic intracerebral hemor­rhage similar to the original NINDS trial [24]. The use of CT per­fusion imaging overcomes practical limitations associated with MRI accessibility and establishes a more universally applicable model for emergency departments (EDs) throughout the United States. The ndings from the EXTEND trial contribute valuable insights into the potential expansion of the treatment window for acute ischemic stroke patients, offering a pragmatic and feasible alternative for EDs in the United States.

To further substantiate the use of IVT guided by perfusion imaging within a 9-hour window, our group has initiated patient enrollment in a trial modeled after the EXTEND trial. Our study similarly uses the modied Rankin Scale to measure improvement after 90days and measures symptomatic intracerebral hemorrhage as a secondary outcome. There is presently a cohort of ve patients showing promising results. If additional trials afrm the safety and efcacy of this extended treatment, stroke protocols may evolve to preserve more salvageable brain tissue in patients with AIS.

A promising alternative is tenecteplase (TNK), a genetically engineered mutant tissue plasminogen activator exhibiting phar­macokinetic advantages such as enhanced brin selectivity and an extended half-life [29]. TNK presents several advantages over alteplase, including simplied dosing calculations, a single bolus administration, and logistical ease of transport between hospital systems, eliminating the need for continuous infusion.

Given the limited eligibility for endovascular thrombectomy (EVT) in a small percentage of AIS patients, there is a compelling need to explore and expand the boundaries of IVT utilization.

Shifting focus from rigid time windows to assessing tissue win­dows through advanced neuroimaging remains crucial. Ongoing randomized controlled trials in this eld, supported by the evolv­ing evidence surrounding TNK, hold the promise of broadening treatment opportunities for acute ischemic stroke patients. Continued efforts in this direction are pivotal for advancing the eld and improving outcomes for individuals affected by isch­emic stroke.