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Multicenter Study
. 2022 Aug;53(8):2426-2434.
doi: 10.1161/STROKEAHA.121.036993. Epub 2022 May 12.

Beyond the Golden Hour: Treating Acute Stroke in the Platinum 30 Minutes

Anantbir S Randhawa  1 , Fatima Pariona-Vargas  2 , Sidney Starkman  3 , Nerses Sanossian  4 , David S Liebeskind  5 , Gilda Avila  5 , Samuel Stratton  3 , Jeffrey Gornbein  6 , Latisha Sharma  5 , Lucas Restrepo-Jimenez  5 , Miguel Valdes-Sueiras  5 , May Kim-Tenser  4 , Pablo Villablanca  7 , Robin Conwit  8 , Scott Hamilton  9 , Jeffrey L Saver  5
Affiliations
Multicenter Study

Beyond the Golden Hour: Treating Acute Stroke in the Platinum 30 Minutes

Anantbir S Randhawa et al. Stroke. 2022 Aug.

Abstract

Background: To emphasize treatment speed for time-sensitive conditions, emergency medicine has developed not only the concept of the golden hour, but also the platinum half-hour. Patients with acute stroke treated within the first half-hour of onset have not been previously characterized.

Methods: In this cohort study, we analyzed patients enrolled in the FAST-MAG (Field Administration of Stroke Therapy-Magnesium) trial, testing paramedic prehospital start of neuroprotective agent ≤2 hours of onset. The features of all acute cerebral ischemia, and intracranial hemorrhage patients with treatment starting at ≤30 m of last known well were compared with later-treated patients.

Results: Among 1680 patients, 203 (12.1%) received study agents within 30 minutes of last known well. Among platinum half-hour patients, median onset-to-treatment time was 28 minutes (interquartile range, 25-30), and final diagnoses were acute cerebral ischemia in 71.8% (ischemic stroke, 61.5%, TIA 10.3%); intracranial hemorrhage in 26.1%; and mimic in 2.5%. Clinical features among platinum half-hour patients were largely similar to later-treated patients and included age 69 (interquartile range, 57-79), 44.8% women, prehospital Los Angeles Motor Scale median 4 (3-5), and early-postarrival National Institutes of Health Stroke Scale deficit 8 (interquartile range, 3-18). Platinum half-hour acute cerebral ischemia patients did have more severe prehospital motor deficits and younger age; platinum half-hour intracranial hemorrhage patients had more severe motor deficits, were more often female, and less often of Hispanic ethnicity. Outcomes at 3 m in platinum half-hour patients were comparable to later-treated patients and included freedom-from-disability (modified Rankin Scale score, 0-1) in 35.5%, functional independence (modified Rankin Scale score, 0-2) in 53.2%, and mortality in 17.7%.

Conclusions: Prehospital initiation permits treatment start within the platinum half-hour after last known well in a substantial proportion of acute ischemic and hemorrhagic stroke patients, accounting for more than 1 in 10 enrolled in a multicenter trial. Hyperacute platinum half-hour patients were largely similar to later-treated patients and are an attainable target for treatment in prehospital stroke trials.

Keywords: blood pressure; cerebral hemorrhage; reperfusion; thrombectomy; transient ischemic attack.

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Figures

Figure 1.
Figure 1.
Histogram showing proportions of patients treated in 5 minute intervals from 0-120 minutes. A) Acute cerebral ischemia patients; B) Intracranial hemorrhage patients
Figure 1.
Figure 1.
Histogram showing proportions of patients treated in 5 minute intervals from 0-120 minutes. A) Acute cerebral ischemia patients; B) Intracranial hemorrhage patients
Figure 2.
Figure 2.
Global disability mRS outcome distributions at 90 days in platinum half-hour and later-treated patients. A) Acute cerebral ischemia patients; B) Intracranial hemorrhage patients
Figure 2.
Figure 2.
Global disability mRS outcome distributions at 90 days in platinum half-hour and later-treated patients. A) Acute cerebral ischemia patients; B) Intracranial hemorrhage patients
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