In patients such mismatch

is usually present during the first 6 h after stroke [22]. Noticeably, HBO2T was effective against experimental stroke if administered when a penumbra is typically present in the brain [23]. HBO2T administered at a time when penumbra is usually gone (e.g. at 23 h) may even be harmful [24]. The clinical trials done with HBO2T so far did not follow this paradigm, which creates the most important discrepancy between experimental and clinical work. We propose that the evaluation of patients in any future clinical trial should include separate subgroup analyses of patients with and without confirmed penumbra as the selleck kinase inhibitor impact on outcomes may be different in these two groups. As the accepted standards of stroke care are paramount in treatment of any patient presenting with acute stroke, patients presenting within the therapeutic window for tPA

should be treated with tPA but should be considered for HBO2T as well if they have persistent neurologic deficits on physical examination and can be treated within the time window. This is because even in cases of temporary ischemia HBO2T has shown benefit in animal studies through decreases in reperfusion injury [25]. Subjects presenting to the ED with a presumed diagnosis of stroke will be evaluated by a neurologist. Inclusion requires the determination of anterior circulation ischemia by the clinical judgment of the examiner, meaning that the stroke is restricted to the middle or anterior cerebral artery territory. Both males and females others at least 18 years-old with onset of symptoms less than 6 h will be evaluated by a LY294002 order certified examiner using the National Institute of Health Stroke Scale (NIHSS) [26]. While this may seem a very high standard in terms of timing, this is consistent with the recommendations of the American Stroke Association recommending that assessment and treatment of acute stroke patients commence within 60 min of presentation to the emergency department [27]. A minimum score of four on the NIHSS is needed for inclusion. The premorbid modified Rankin scale score (mRS) will

be evaluated by discussing with the patient/family as assessment of baseline neurologic function [28]. If the patient scores above a mRS of 0–1, or it is unable to be assessed, the patient will be excluded. Treatment must begin, i.e. the chamber door must be closed, within 6 h of the onset of symptoms. Patients who are candidates for tPA will be included, but must complete their tPA treatment prior to undergoing HBO2T. As most patients receiving tPA do so in the first 3 h, and the infusion lasts one hour, this does allow time to complete the treatment and then proceed to the hyperbaric chamber. A non-contrast head CT at presentation will be reviewed to assess for ICH or other intracranial pathology that would warrant exclusion.