The first all-inclusive update to the AHA/ASA Guidelines for Acute Ischemic Stroke was released in January at the International Stroke Conference in Los Angeles. Progressnotes spoke with Edward C. Jauch, M.D., interim chair of the Department of Emergency Medicine at MUSC and one of the national authors of the 2013 guidelines and subsequent revisions, about what’s new in the latest update.
PN: Why was an update to the guidelines needed?
Acute stroke has been rapidly evolving over the last five years largely due to the development of endovascular therapies, where catheters are inserted through the arteries to go up and directly remove the clot using special devices. The other thing that is changing in stroke care in general is the development of regional stroke systems of care. We are recognizing that hospitals within a region need to collaborate to manage stroke patients most effectively. So we are emphasizing the importance of stroke capability credentialing, stroke recognition in the pre-hospital setting, understanding the severity of the stroke and getting the patient to the most appropriate hospital based on that stroke severity.
PN: What are the new guideline recommendations for thrombolytic therapy?
Some years back, we expanded the treatment window for alteplase out to 4.5 hours for carefully selected patients. We have also started to remove some of the absolute contraindications to the drug based on 20 years of experience, so more people are eligible for treatment. More importantly, we have recognized that door-to-needle (DTN) time, as we call it — how quickly we administer the drug once the patient has entered the emergency department — is very important in terms of the patient’s outcome. So we are developing these systems of care to ensure that we minimize any delays that could prevent the patient from actually getting the medication. Building these systems of care within a region and within a hospital to effectively deliver this in a timely fashion has become an important part of the guidelines. And so we have established some new time benchmarks. It used to be that we wanted patients treated within 60 minutes of arriving at the emergency department. Now we want to administer alteplase even quicker, since we realize it is an attainable goal. So now we want DTN to be under 45 minutes, and ideally you could probably drive it down to 30 minutes. And for every 15 minutes you decrease it, more patients will have a good outcome and survive their stroke.
PN: What are the new guideline recommendations for endovascular therapy?
Endovascular therapy as standard of care really came about in 2015 with the publication of five positive clinical trials. Based on those results, we issued a guideline update at that time recommending endovascular therapy with stent retrievers out to six hours. But now, as we are using more advanced imaging such as MRI and computed tomography (CT) perfusion, we are able to identify tissue that is still salvageable in the brain beyond the traditional six hours. So now we can get patients who wake up with a stroke or are found down with a stroke in the last 24 hours and — if the imaging that we perform shows that there is still salvageable brain — then we are able to go up into these large arteries and perform mechanical embolectomy with these new devices. Patients beyond 4.5 hours are not eligible for the drug alteplase but are now potentially eligible, if they have a large clot and salvageable brain, to have the catheters remove the clot directly.
PN: What do the guidelines say about optimal in-hospital care?
We have created all sorts of new processes that are more effective in getting patients through the entire in-hospital system of care. That starts with Emergency Medical Services (EMS) bringing the patient to the right hospital based on the severity of the patient’s symptoms. It starts with them telling the receiving hospital they’re coming through advanced notification. With that notification, we can take patients straight to the CT scanner, because that is a rate-limiting factor in determining eligibility for therapies. We give alteplase to all patients who come in within 4.5 hours of symptom onset and meet criteria. And then, based on the recent DAWN and DEFUSE 3 trials, we very quickly perform additional imaging to see if there is a large vessel within the brain obstructed by a clot, if it’s in an area from which we can actually retrieve it and if there is still brain that can be salvaged. If so, and it’s still within 24 hours of symptom onset, then we rapidly get the patients to the neurointerventional suite, where they undergo an embolectomy.
But there has to be salvageable brain — opening up a blood vessel to dead brain doesn’t do any good.
PN: How have the criteria for evaluating stroke care changed?
In the past, we have looked at hospitals in terms of being stroke centers based on their infrastructure. What I mean by that is that we would say: “Do you have a CT scanner? Do you have an emergency department? Do you have a stroke expert either in-house or now by telemedicine?” But that’s just really telling us if you have the infrastructure. It doesn’t tell us how well you use it. So we are evolving fairly quickly across the country with our credentialing and with guidelines to look at patient-centric outcomes. We are looking not only at whether you have those tools and resources, but also whether they produce meaningful outcomes for the patients. If you have all of the resources but don’t use them effectively, the patients suffer. So we are going toward a more public reporting of your performance. The Centers for Medicare and Medicaid Service are wanting this. The public wants this. And it will help regional areas understand how well individual hospitals work within that region. For a Comprehensive Stroke Center like MUSC, it will help us identify hospitals in our region that may need our help. And for health care systems, it will tell them where they need to place additional resources. And when that becomes publicly available at the state level, that will help EMS agencies understand where’s the best hospital to take stroke patients.
For an unabridged version of this interview, visit the Neurosciences page of the MUSC Health Medical Video Center (MUSChealth.org/medical-video)