Highlights: AHA/ASA 2018 ischemic stroke guidelines

More patients could now be eligible for critical procedures and medications following an acute ischemic stroke (AIS), the American Heart Association and American Stroke Association announced in their latest joint treatment guidelines.

The guidelines, which were released at the AHA’s annual International Stroke Conference in Los Angeles on Wednesday, are the first fresh set of recommendations for treating AIS since 2016. Guideline writing chair William J. Powers, MD, led a team of experts in analyzing more than 400 peer-reviewed studies before publishing their official recommendations in Stroke this week.

“Just a few years ago, stroke dropped from the nation’s No. 4 killer to No. 5, yet it still kills more than 130,000 people every year,” Powers wrote in a commentary published on the AHA site. “That’s why the AHA/ASA hasn’t rested in its determination to treat and beat stroke—and that’s why today we released new acute ischemic stroke treatment guidelines.”

Though the team issued a list of recommendations that stretched 65 pages, Powers said two were most notable:

An extended window for thrombectomies

This guideline recommends increasing the time an AIS patient is eligible for a mechanical thrombectomy—a procedure in which blood clots are mechanically removed from vessels supplying the brain—from six hours to 24. Because of the nature of the sometimes-risky procedure, clinicians have in the past recommended mechanical clot removal only for patients with large vessel strokes. This recommendation holds in 2018, but Powers and his colleagues found that large vessel clots can be removed safely via mechanical thrombectomy for up to 16 hours after a stroke. In certain cases, the authors wrote, patients could have up to a full day.

“The expanded time window for mechanical thrombectomy for appropriate patients will allow us to help more patients lower their risk of disability from stroke,” Powers said in an AHA release. “That’s a big deal. That’s potentially a lot more people who could benefit, and it has completely changed the landscape of acute stroke treatment.”

Expanded  eligibility for alteplase

Though the tissue plasminogen activator known as alteplase is a common stroke medication and the only clot-dissolving treatment approved by the FDA for ischemic stroke patients, not all patients have access to it. Based on prior research, clinicians have avoided administering alteplase to mild stroke patients, but Powers et al. found alteplase to be helpful in a fraction of that population—especially in reducing disability rates post-stroke.

In the 2018 guidelines, alteplase is recommended for both major stroke patients and, if administered to minor stroke patients within a three- to 4.5-hour window of the stroke event, a handful of minor stroke patients, too.

“It potentially increases the number of people getting intravenous clot-busting treatment,” Powers said.

In addition to these expanded treatment options, Powers and the board outlined several other recommendations:

• Getting to the hospital effectively in an emergency. Though many people resort to self-transportation to the ER, Powers said it’s actually smarter to call an ambulance than buckle up in your own vehicle. By calling 911, he said, patients allow hospitals time to prepare for immediate AIS treatment as soon as they reach the ER. In the guidelines, Powers and co-authors recommended that public health leaders pair with medical professionals to implement public education programs focused on emergency care and getting stroke patients to the hospital.
• Certifying stroke centers. Data support the development of stroke centers to improve patient care and outcomes, the authors wrote. Specialized centers certified by the Center for Improvement in Healthcare Quality, Det Norske Veritas, Healthcare Facilities Accreditation Program, the Joint Commission or a state health department have yielded more favorable results.
• Delivering care quickly. A brand-new recommendation suggests it could be reasonable to shoot for a 45-minute door-to-needle goal for patients with AIS who were treated with IV alteplase.
• Using video chat to save lives. If a center isn’t well-equipped to deal with a stroke case—if there are no neurologists or ER doctors trained to use alteplase onsite—Powers and colleagues recommended video conferencing with trained stroke professionals at other institutions. Research has proven the “telestroke” approach can save lives just as effectively as an on-call neurologist could.
• Brain imaging. IV alteplase and mechanical thrombectomy can both be live-savers, but they’re time dependent, too. The board suggested a 20-minute limit for performing brain imaging on stroke patients after their arrival at the ER. The imaging can aid initial evaluations and help determine which patients are suited for which treatments.

The full set of guidelines can be found online.

Karen L. Furie, MD, MPH, and Mahesh V. Jayaraman, MD, lauded Powers’ team for their work on the 2018 guidelines in a Stroke editorial.

“To quote Thoreau, ‘When any real progress is made, we unlearn and learn anew what we thought we knew before,’” they wrote. “The stroke field had made enormous progress in the past five years, and (these guidelines) will elegantly serve as a primer for updating our knowledge.”