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The past 15 years have witnessed significant strides in the management of acute stroke. The most significant advance, reperfusion therapy, has changed relatively little, but the integrated healthcare systems-stroke systems-established to effectively and safely administer stroke treatments have evolved greatly. Driving change is the understanding that "time is brain." Data are compelling that the likelihood of improvement is directly tied to time of reperfusion. Regional stroke systems of care ensure patients arrive at the most appropriate stroke-capable hospital in which intrahospital systems have been created to process the potential stroke patient as quickly as possible. The hospital-based systems are comprised of prehospital care providers, emergency department physicians and nurses, stroke team members, and critical ancillary services such as neuroimaging and laboratory. Given their complexity, these systems of care require maintenance. Through teamwork and ownership of the process, more patients will be saved from potential death and long-term disability.

Although septic cavernous sinus thrombosis represents a rare cerebral vascular event, the morbidity and mortality can be profound. Diagnosis of this disease remains challenging, despite recent advances in imaging technology. We present a 71-year-old man who presented with symptoms of retro-orbital pain, swelling and a recent history of being treated for bacterial sinusitis. An initial non-contrast head computed tomography showed a dilated, hyperdense appearance of his left superior ophthalmic vein, with subsequent magnetic resonance imaging suggestive of bilateral ophthalmic vein thrombosis likely from cavernous sinus origin. The patient had blood cultures positive for Streptococcus anginosus, and was successfully treated with several weeks of i.v. antibiotics and anticoagulation.