If you know anything about stroke, it’s probably this: it’s critical to get emergency medical care fast. Even 15 minutes can mean the difference between disability and a normal life moving forward.
That need for speedy treatment has not changed. But what has are the options doctors have in treating stroke patients, according to new guidelines from the American Heart Association and American Stroke Association. Now, more people will be eligible for potentially lifesaving care for a larger window of time.
The new standard of care was developed by a group of experts chaired by William J. Powers, MD, chair of the neurology department at the UNC School of Medicine. The guidelines apply to acute ischemic strokes, the most common type, which occur when a blood clot blocks an artery leading to the brain and cuts off blood flow. The lack of blood causes brain tissue to die.
Under the new guidelines, two major things have changed:
- More patients are eligible to receive the clot-busting IV drug alteplase. For example, people with aneurysms and people older than 80 will no longer face automatic restrictions on the drug, which can be used for 4.5 hours after stroke onset.
- A newer treatment, mechanical thrombectomy, which involves pulling a clot out of the brain through a tube, is now recommended in some patients for as many as 24 hours after the onset of stroke. Previously, the window was six hours.
“This is a huge deal….Now, if you went to bed 10 hours ago and go to the hospital, we know it may still be worthwhile to pull that clot out.”
“This is a huge deal. It used to be if you woke up after having gone to bed six hours before with stroke symptoms, there was nothing we could do,” Dr. Powers says. “Now, if you went to bed 10 hours ago and go to the hospital, we know it may still be worthwhile to pull that clot out.”
That said, Dr. Powers and other stroke experts are adamant that you not put off calling 911 if you have stroke symptoms, such as facial drooping, arm weakness or speech difficulty. And don’t drive yourself to the hospital or have someone else drive you, either—the paramedics can prepare the emergency department for your arrival. Every minute still counts.
“With all these treatments, the faster you do it, the better,” Dr. Powers says. “Just because some people can benefit up to 24 hours, if they’re treated at 12 hours, that’s better. If they’re treated at six hours, that’s better. And if they’re treated within two hours, that’s better.”
Virtually all emergency departments will have access to alteplase, also called TPA, for tissue plasminogen activator. The drug dissolves clots and can be used for strokes of any severity, though it’s less effective for severe strokes in which the clots are bigger and harder to break up, Dr. Powers says.
Mechanical thrombectomy is effective only for larger clots that cause more serious strokes and that are located near the base of the brain. The procedure is available at large stroke centers, such as UNC’s, and the two treatments can be used in tandem.
On average, UNC receives a call or two per day from a smaller hospital asking whether a patient it has might be a candidate for mechanical thrombectomy, Dr. Powers says. If the patient is eligible, the regional facility will administer alteplase, if indicated, and a helicopter will bring the patient to UNC for the procedure.
The last time the American Heart Association/American Stroke Association put out comprehensive guidelines for acute ischemic stroke was 2013. In the time since, much has been learned by Dr. Powers and his colleagues, who spent the past several months reviewing more than 400 published studies.
The new guidelines are intended for general practitioners, emergency department doctors, specialists and other health care professionals—basically anyone who encounters a patient having an acute ischemic stroke.
The guidelines don’t apply to other kinds of stroke, such as hemorrhagic stroke, in which a blood vessel ruptures and bleeds into the brain, and transient ischemic attack (TIA), a temporary clot that’s sometimes called a ministroke.
Again, the sooner any stroke treatment is deployed, the better. People with symptoms shouldn’t wait to see if they feel better.
“Let us decide if it’s a stroke or not. That’s what we’re trained to do,” Dr. Powers says. “We now have more we can do for people to help them get better, but still call 911 and don’t wait.”