January 29, 2018 – The updated guidelines were issued last week at the 2018 International Stroke Conference.
Last week the American Heart Association and American Stroke Association issued new guidelines for the management of ischemic strokes, which account for about 85 percent of all strokes. The new guidelines expand the window for thrombectomy from six to 24 hours, based on the results of brain imaging in select patients. We asked the DCRI’s Bradley Kolls, MD, associate professor in the Department of Neurology, to weigh in on the implications of these changes.
What do the new guidelines mean for clinicians?
Within the new guidelines we now have the highest level of evidence for interventional treatment of the largest and most devastating stroke, those that result from large vessel occlusions. Much like ischemic myocardial infarction 20 years ago, percutaneous intervention with catheters and clot removal tools have been found to be superior than just blood clot lysis therapy alone. What is even more exciting is that new studies using these interventional approaches are showing benefit to patients at very extended time periods after onset, now up to 24 hours after the last time patients were seen well. These new criteria for identifying patients who will benefit from endovascular therapy represent another big step forward in acute stroke care and present some real challenges for us in terms of implementation into clinical practice.
What role does technology play in the new guidelines?
The selection criteria require the use of software to automate the interpretation of vascular imaging studies to determine specific features about the area of the brain that is involved in the stroke. The implementation of the software and developing the systems of care to obtain the needed testing and analysis in a timely way will require close partnerships with referring partner centers. Our telestroke system will offer a solid platform for deployment, though will take some time to coordinate across the centers in the network. The new guidelines also support the development of multidisciplinary teams within facilities that develop and enforce the use of a highly organized process for acute stroke assessment and evaluation. The use of goals for delivery of TPA and the further development of systems of care that begin with emergency medical services are all high-level supported aspects to optimal acute stroke care. Telemedicine was also addressed in the guidelines and there is growing evidence and support for the benefits of using a telestroke service to improve the care and delivery of TPA and other acute stroke interventions.
Do you have any concerns about the new guidelines?
Some of the guidelines around the care in the hospital lack strong recommendations despite being prominent aspects of care, and the current focus of many quality measures for stroke care. An example is the dysphagia screen and the use of deep vein thrombosis prevention such as subcutaneous heparin or low-molecular weight heparin. It seems the lack of data on clear benefit in terms of long-term outcome and the cost of these interventions has led to a modest support statement for what many stroke providers feel are critical aspects to stroke care and recovery. Similarly, the use of MRI and vascular imaging, and obtaining ECHOs (heart ultrasound) routinely to try to determine the cause for the stroke and implement appropriate secondary prevention strategies was not recommended. This is quite counter to current shared best practice by most centers and was hotly contested and debated at the open guidelines sessions. Again, lack of impact on outcomes and uncertain cost-benefit were cited as the reasons for the recommendations. However, many argue that absence of proof is not proof of absence. No one questions the improved outcomes of wearing a parachute when jumping from an airplane compared to not wearing one.
What do these guidelines mean for the future of stroke care?
Acute stroke care has seen some of the greatest advances in all of neurology over the past five years and we continue to find new and better ways to help patients having an acute stroke. Interventions on hemorrhagic stroke and intense research on the systems of stroke care will help even more patients receive the care they need in the shortest times possible, and hopefully will lead to continued gains in the functional outcomes and quality of life for our patients. The direct oral anticoagulants continue to be expanded in their use in stroke prevention and may one day become the best preventive strategy for most stroke patients and help reduce the need for the detailed testing that today forms the basis for controversy over the new guidelines. Stroke remains an exciting and evolving field and new technologies and therapies are rapidly converging in this field to completely change how we treat and manage acute stroke.