Literature Review
Thrombectomy at Six to 24 Hours After Stroke May Improve Outcomes
Compared with standard care alone, standard care plus endovascular thrombectomy at six to 24 hours after stroke onset appears to reduce disability...
LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.
William J. Powers, MD
The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.
Prehospital Care
The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.
IV and Intra-Arterial Therapies
IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.
The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.
The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.
In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.
The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.
Diagnostic Tests
Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”
—Erica Tricarico
Suggested Reading
Powers WJ, Rabinstein AA, Ackerson T, et al. 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. Stroke. 2018 Jan 24 [Epub ahead of print].