Updated Ischemic Stroke Guidelines: Expert Takeaways
More patients will be eligible to receive alteplase under the new guidelines.
Although stroke has moved down the list from the fourth to fifth most common cause of death in the United States, more than 130,000 Americans still die from stroke each year.1 At the 2018 International Stroke Conference in Los Angeles, the American Heart Association/American Stroke Association (AHA/ASA) released updated guidelines for the early management of ischemic strokes, which account for 87% of all strokes.2 The recommendations are based on more than 400 studies and contain revisions to the previous set of guidelines published in 2013.
“The update represents considerable careful, interdisciplinary discussion,” Albert Favate, MD, division chief of vascular neurology at NYU Langone and associate professor at NYU School of Medicine, told Neurology Advisor. “There are points of controversy in this area, and it is impressive that the AHA is engaging in ongoing dialogue to arrive at a consensus.”
In a related commentary by the chair of the writing group that produced the guidelines,3 William J. Powers, MD,FAHA, the H. Houston Merritt Distinguished Professor and department chair in the Department of Neurology at the University of North Carolina at Chapel Hill, noted 2 especially significant changes: The window of time to perform thrombectomy has been increased from to up to 24 hours for carefully selected patients, based on results from the DAWN and DEFUSE 3 trials4,5; and because of several revisions, a greater number of patients may now be eligible for alteplase.
In an interview with Neurology Advisor, Dr Favate highlighted other notable points from the guidelines, as summarized below.
- Emergency medical services (EMS) leaders should coordinate with medical experts and local, regional, and state agencies to create triage paradigms and protocols to facilitate the rapid identification and assessment of patients with stroke or suspected stroke. This should involve the use of validated stroke screening tools such as the Face Arm Speech Test (FAST), the Cincinnati Prehospital Stroke Scale, or the Los Angeles Prehospital Stroke Screen.
- The statement regarding the formation of regional systems for stroke care has been reworded from the previous guidelines. “This is significant in that it provides definite language encouraging collaboration between EMS, hospitals, and regional governments to form efficient stroke networks — a positive move by the AHA/ASA in that the language is highly supportive of the formation of integrated systems for the triage and treatment of stroke patients,” according to Dr Favate.
- “A major point of debate pertains to an item about bypassing a primary stroke center to transport the patient to a comprehensive stroke center offering mechanical thrombectomy” said Dr Favate. While this is new in the guidelines, the authors concluded that further research is needed before a definitive recommendation can be made. Although there are 6 prehospital stroke severity scales, there is “no consensus on which is best for triage to a comprehensive stroke center if there is less than 15 minutes of additional transit time above transport to a primary stroke center.”
- In a revision from the 2013 guidelines, the new version recommends the establishment of a door-to-needle (DTN) time goal of ≤60 minutes in ≥50% of AIS patients treated with IV alteplase. “What is new is discussion about DTN times of 45 minutes or less in 50%of patients with acute ischemic stroke” as a secondary goal, Dr Favate noted. “This is most significant as it helps to maximize the critical timeline in stroke triage and initiation of treatment with tPA [tissue plasminogen activator].”
- A few of the new or revised items in a section on telemedicine include the use of teleradiology and telestroke services for the expedited review of neuroimaging at sites without such capabilities in house; telestroke guidance for tPA administration; and telestroke decision support pertaining to the potential transfer of patients for thrombectomy.
- It is now recommended that hospitals participate in a stroke data repository to promote adherence to current guidelines, improve patient outcomes, and facilitate quality improvement.
- Hospitals should establish systems to allow the performance of brain imaging studies within 20 minutes of arrival to the ED in ≥50% of patients for whom IV alteplase and/or thrombectomy may be indicated.
- Providers should not use the CT hyperdense middle cerebral artery sign as a criterion to withhold tPA from patients who would be candidates otherwise.
“The 2018 guidelines summarize the current best practice recommendations while acknowledging that there are areas of uncertainty that require further work,” Dr Favate concluded.
- Powers WJ. In light of new guidelines, here are three things everyone should know about stroke. AHA Centers for Health Metrics and Evaluation; January 24, 2018. Accessed January 25, 2018.
- Powers WJ, Rabinstein AA, Ackerson T, et al; on behalf of the American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published online January 24, 2018]. Stroke. doi:10.1161/STR.0000000000000158
- Jauch EC, Saver JL, Adams HP, et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.
- Nogueira RG, Jadhav AP, Haussen DC, et al; for the DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018; 378:11-21.
- Albers GW, Marks MP, Kemp S, et al; for the DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging [published online January 24, 2018]. N Engl J Med. doi:10.156/NEJMoa1713973