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Clot-bustingdrugs – extending the effective timewindowandmaking themreadily availableworldwide PROFESSOR WERNER HACKE All three trials and a pooled analysis of the trials 4 pointed in the same direction: if advanced imaging confirms either a very recent onset of stroke or the presence of penumbral tissue (tissue surrounding the stroke that is still viable), the use of Alteplase results in a better functional outcome compared with placebo treated patients. In patients with an unknown time window, a computer aided selection algorithm is superior to an eyeballing approach to identify the tissue at risk. In 2019, theWorld Stroke Organization included Alteplase (a clot-busting drug) in the list of essential drugs, meaning that all member countries must take the steps necessary to allow access to this treatment. As there are major differences in the cost of Alteplase between countries, Professor Hacke and his team set out to explore the availability, pricing and current usage of the drug in countries with different health care systems, GDP and health care expenditure. They included high income, high middle income and lowmiddle income countries. Although the data is yet to be published, it gives a very clear indication of the obstacles that patients will face in receiving this essential drug. Furthermore, Professor Hacke has also recently published 5 on age and sex differences in access to stroke treatment for both IVT and Mechanical Thrombolysis (MT or clot retrieval). This study was based on a nationwide analysis of all hospitalised ischaemic stroke patients in Germany from 2013 to 2017 – 1.11 million people! They found that men of all age groups had a significantly higher probability of receiving stroke unit treatment, while women of all ages were treated more often with MT and patients ≥80 years of age received treatments significantly less often. There was no difference in the rate of IVT between men and women. The current IVT rates in Germany are 16.5% and the MT rate in 2018 was 6.5%, which shows what is possible when a nationwide comprehensive stroke care system is available to all. Professor Hacke’s main scientific and clinical interests are in stroke and critical care neurology. He has pioneered the field of hyper-acute stroke management including hyper-acute stroke units, critical care of stroke, recanalising therapies including intravenous thrombolysis (IVT or clot-busting drugs) and initiated several new management options for life threatening infections including decompressive surgery. Professor Hacke (MD PhD DSc (Hon)) holds degrees in both medicine and psychology and is a board-certified neurologist and critical care specialist in Germany. In 1987, at the age of 39, Professor Hacke became Chairman of the Department of Neurology at the University of Heidelberg in Germany. He was Professor and Chair for 27 years until September 2014 and is now the first Senior Professor in the Heidelberg University Faculty of Medicine. He was the Founding President of the European Stroke Organization, Vice President of theWorld Federation of Neurology and most recently the President of theWorld Stroke Organisation. He is past President of the German Neurological Society, the German Society for Neurocritical Care and the German Interdisciplinary Critical Care Society. Professor Hacke is an honorary member of many national and international societies for neurology, stroke medicine, critical care, neurosurgery and neuroradiology, and has published more than 500 original articles with greater than 105,000 citations. Furthermore, he has written and edited the largest German language textbook on Neurology(‘Neurologie”) currently in its 14th edition (Springer publishers). In the past two years Professor Hacke and his research team have received the results of three clinical trials exploring the use of the clot-busting drug, Alteplase, outside the approved 4.5h timeframe after patients have suffered a stroke. One study concentrated on a group of patients who suffered a stroke overnight and therefore had an unknown time window (WAKE UP 1 ). The two other trials included both wake up strokes and late arrivals with a known time of stroke onset (ECASS 4 Extend 2 and EXTEND Australia 3 ). Professor Werner Hacke is a neurologist, critical care specialist and Senior Professor in the Faculty of Medicine at Heidelberg University. He has played a leading role in stroke treatment and prevention trials and has provided us with an update on advances in the field. 1 Stroke. 2020 Jan;51(1):209-215. 2 Int J Stroke. 2019 Jul;14(5):483-490. 3 N Engl J Med. 2019 May 9;380(19):1795-1803. 4 Lancet. 2019 Jul 13;394(10193):139-147. 5 Stroke. 2019 Dec;50(12):3494-3502. Headlines 11