Stroke: Time Is Still Brain (CME/CE)

Published: Jan 31, 2013

By Chris Kaiser, Cardiology Editor, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Stroke treatment within 60 minutes, telestroke networks, and expanded eligibility for clot-buster therapy are among the topics outlined in the new stroke guidelines from the American Stroke Association published in Stroke: Journal of the American Heart Association.

Many of the so-called new guidelines are a simple statement of accepted clinical practice, such as treating eligible stroke patients with IV tissue plasminogen activator (tPA) within 60 minutes of arriving at the hospital, Edward C. Jauch, MD, lead author of the document, told MedPage Today.

But it has been 6 years since the last stroke treatment guidelines were published and the new document contains 21 new recommendations as well as 50 revisions of existing recommendations. Another 42 recommendations remain unchanged.

"The guidelines are a progression of what the stroke community is learning and a nod toward the direction we're heading," said Jauch, director of the division of emergency medicine at the Medical University of South Carolina in Charleston.

One of the new recommendations states that tPA can be administered to stroke patients where the treatment was previously contraindicated. These include those with a minor stroke, a rapidly improving stroke, recent major surgery, or a recent heart attack (class IIb, level of evidence C).

"Several studies have now reported that approximately one third of patients who are not treated with intravenous tPA because of mild or rapidly improving stroke symptoms on hospital arrival have a poor final stroke outcome," according to the guidelines.

Guidelines also noted that patients may have "potentially disabling symptoms even though their NIH Stroke Scale score is just 2."

One of the biggest changes in stroke care is the involvement of whole regions to offer coordinated care rather than relying on a single hospital to do everything.

"Different hospitals have different capabilities for taking care of our sickest stroke patients," Andrew Russman, DO, of the Cleveland Clinic, who was not on the writing committee, told MedPage Today. "Some of the new guidelines suggest that we should reroute patients from hospitals that have lesser capability to those that have more capabilities."

Emergency medical personnel should be aware of the various levels of stroke care offered in their community, including

  • Comprehensive stroke centers -- which offer 24/7, highly specialized treatment for all types of stroke
  • Primary stroke centers -- which provide 24/7 specialized care mainly for ischemic stroke
  • Acute stroke-ready hospitals -- which can evaluate and treat most strokes but lack highly specialized capabilities

Also new is an emphasis on creation of acute stroke-ready hospitals in regional systems of care (class IIa, level of evidence C).

EMS also need to be ready to bypass hospitals that may not offer certain procedures, such as advanced CT or MRI imaging (which is recommended before IV tPA [class I, level of evidence A]).

When none of these hospitals are available, the guidelines state that telestroke consultation can be used to access stroke treatment expertise (class IIa, level of evidence C). Along with telestroke, the guidelines also recommend the use of teleradiology systems for fast and accurate image interpretation.

During an acute stroke, physicians must quickly evaluate and diagnose the patient as soon as possible to determine if patients are eligible to receive tPA, which can be given within 4.5 hours of symptom onset.

The FDA has approved tPA to be given within a 3-hour window of symptom onset. In Europe, the clot-busting drug is approved for up to 4.5 hours.

Genentech, maker of tPA, asked the FDA to approve the drug for the extended 4.5-hour time frame and provided the agency with additional data. But the FDA last spring declined the request.

That move by the FDA interested the guideline writing committee because it had endorsed the extended therapeutic window in 2009, Jauch told MedPage Today. "We wanted to be sure we weren't advocating something for our patients that would harm them."

A few members of the writing committee reviewed the additional data with representatives of Genentech. Although the FDA gave no reason for declining the request, the writing committee was satisfied the reason was not based on safety concerns, Jauch said.

"We felt we should continue to maintain our recommendation that the administration of tPA could be considered for up to 4.5 hours of symptom onset in select patients," he said.

Other new recommendations:

  • Multidisciplinary quality improvement committees should be created within hospitals to review and monitor stroke care quality (class I, level of evidence B)
  • Recently introduced stent retrievers could potentially remove large blood clots more completely and quickly than tPA. Solitaire FR and Trevo are preferred for coil retrievers over the Merci device when mechanical thrombectomy is used (class I, level of evidence A)
  • Patients already on statins when presenting with stroke can continue taking them during the acute phase (class IIa, level of evidence B)
  • The use tPA in patients taking direct thrombin inhibitors, such as dabigatran (Pradaxa) or direct factor Xa inhibitors, such as rivaroxaban (Xarelto) or apixaban (Eliquis) is not recommended unless certain tests are conducted beforehand such as activated partial thromboplastin time or ecarin clotting time (class III, level of evidence C)

"Time is brain when it comes to the onset of stroke symptoms," Russman emphasized. "For each minute the brain goes without blood flow, there are 1.9 million nerve cells that are dying, that affect 14 billion nerve connections and 7.5 miles worth of never fibers.

"What this tells us is we should treat patients as quickly as possible to reduce the likelihood they will have disability from a stroke."

Jauk reported a relationship with Genentech and Novo Nordisk. Some of the co-authors reported relationships with Boehringer Ingelheim, Concentric Medical Ferrer Therapeutics, AGA Medical, BrainsGate, BoAxia, Covidien/ev3, ImaRx, Talecris, Lilly Pharma, Pfizer, Medtronic, Merck, Schering-Plough, NIH, Penumbra, ESP Pharma, Cornerstone Therapeutics, Abbott Vascular, Cordis, Atrium, Lutonix-Bard, IDEV, Vortex, Boston Scientific, Invatec, Angioguard, Micell, CardioMEMS, Contego, endospan, EKR Pharmaceutical, Sanofi, GE Healthcare, Phillips Healthcare, NeuroLogica, AstraZeneca, and LifeImage.