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MGH Emergency Department Acute Stroke Protocol for Thrombolysis (IV/IA)

Prior to making any medical decisions, please view our disclaimer.

This protocol was developed and approved by the multidisciplinary Acute Stroke Quality Taskforce and outlines the major responsibilities for the urgent evaluation and treatment of acute stroke patients who present to the ED.

Please refer to other guidelines for the management of inpatients with acute stroke symptoms .

Protocol Activation

Activate the Acute Stroke Protocol (group page ED2CT) for all patients who were Last Seen Well (LSW) less than 12 hours before ED arrival with acute neurological symptoms. In cases with fluctuating symptoms, those with complex issues, or who may be candidates for acute clinical research, the protocol should also be activated, independent of LSW time.

NIH and DPH Recommended Time Targets

The following chart outlines the Time Targets mentioned in the Massachusetts Department of Public Health Primary Stroke Service (DPH PSS) Regulations and recommended by the NIH NINDS Consensus Panel, [ref 1-5]. It is included to aid assessment of the timeliness of activities related to stroke evaluation and diagnosis.

Emergency Department Process Measure Assessment Tool
Activity Recommended Time Targets MGH ED Time Targets
Door to physician ≤ 10 minutes ≤ 5 minutes
Door to stroke team ≤ 15 minutes ≤ 5 minutes
Door to CT or MRI scan initiation ≤ 25 minutes ≤ 25 minutes
Door to CT or MRI scan interpretation ≤ 45 minutes ≤ 30 minutes
Time from order of lab tests to completion of tests, report of results, and interpretation ≤ 45 minutes ≤ 30 minutes
Door-to-needle for IV (t-PA) ≤ 60 minutes ≤ 45 minutes

The protocol is divided into the following sections:


  1. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. doi: 10.1161/STR.0b013e318284056a. Epub 2013 Jan 31.
  2. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):483S-512S.American Heart Association. Guidelines for Cardiopulmonary Resuscitation Emergency Cardiovascular Care. Circulation. 2000, 102 (suppl I): I-1–I-384.
  3. National Institute of Neurological Disorders and Stroke Symposium. Improving the chain of recovery for acute stroke in your community: task force reports. Bethesda, MD: National Institutes of Health, Department of Health and Human Services; 2003.
  4. Marler JR, Jones PW, Emr M, eds. Setting New Directions for Stroke Care: Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, MD: National Institute of Neurological Disorders and Stroke; 1997
  5. Bock BF. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke: Response System for Patients Presenting With Acute Stroke. Accessed August 23, 2011.

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In the News

The MGH Neurology Department placed 4th in US News Neurology / NeuroSurgery rankings for 2013-14.

Educational Video

Still from the Stroke Evaluation simulation

This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.