What you need to know about the new stroke guidelines

Monday, September 3, 2018

New stroke guidelines give physicians more time to treat strokes that meet certain criteria.

Blood clots blocking big blood vessels can be removed up to 24 hours after a stroke.

Know the symptoms and call 911 if you see any of them.

When you have a stroke, time is of the essence in getting to the hospital. But once you are there, you may have much more time to actually be treated, according to new stroke guidelines issued by the American Heart Association and the American Stroke Association.

“The dramatic change from previous guidelines is that the time window in which we can treat stroke patients has been extended from six hours to 24 hours,” says Ted Lowenkopf, MD, medical director of the Providence Joint Commission Comprehensive Stroke Center, Oregon region. “That means that patients who previously had disabling strokes can now be treated up to 24 hours after the stroke occurs, assuming they meet certain criteria. The take-home message for patients is still the same: If you recognize symptoms of stroke, call 911. What hasn’t changed is that early treatment is your best guarantee to have the potential to reverse the disabling symptoms of stroke.”

Are you at risk for stroke? Take a quick quiz and assess your stroke risk.

How the guidelines were developed

Most strokes are caused when a blood clot enters the brain and blocks a blood vessel. A clot-dissolving medication called alteplase can be given in the first three to four and one-half hours after a stroke occurs. Alternatively, the clot could be removed via a wire that is snaked from an artery in the groin up to the brain, where a device called a stent retriever is deployed. It expands for five minutes and then the clot is pulled out. This procedure was traditionally done only within the first six hours after a stroke.

The change in the guidelines, which were put into place in January 2018, is based on two studies, the DAWN study and the DEFUSE 3 study. “What these studies did, which was a radical innovation, was to say that time is one of the critical features that predicts who benefits from getting the blood clot taken out,” Dr. Lowenkopf says. “The DEFUSE 3 study looked at patients in the six- to 16-hour time window, and the DAWN study looked at patients in the six- to 24-hour window. What they did that was innovative is they took a picture of the brain. In strokes where a large vessel was blocked by a blood clot, they could use perfusion imaging to determine whether opening up the blood vessel would be beneficial. The image could determine if there was salvageable brain tissue that’s still getting enough blood flow.”

In these studies, patient treated with the clot retrieval device had nearly a 50% chance of surviving their stroke with minimal or no disability. That chance was about 17% in those not receiving treatment. Based on these results, stroke treatment guidelines were rewritten to include patients in an expanded 24-hour window.

If you don’t live near a facility that performs this clot-removal procedure, you’ll want to make sure your hospital is part of a telestroke network, where an expert in the field can assess you remotely.

The Providence Telestroke Network provides hospitals throughout Oregon and Southern Washington with an around-the-clock portal to Providence Stroke Center, improving stroke care and producing evidence-backed results.

When a patient goes into an ER, he will get a CAT scan, which is an x-ray of the head and the brain, and that will show whether it’s a bleeding or nonbleeding stroke. “Roughly 15 percent of strokes are not caused by a blood clot but by bleeding in the brain, so those people are not candidates for treatment,” Dr. Lowenkopf says.

If it’s a nonbleeding stroke, the patient will get a CT angiogram to see if it’s a larger blood vessel that is blocked. If it’s a larger vessel and it’s still within the six- to 24-hour window, the patient will be transferred to a hospital with perfusion imaging and the capability to remove the clot. (If it’s a smaller blood vessel, the device can’t retract the clot. Those patients usually respond better to clot-dissolving medication, but treatment needs to happen earlier than with the clot removal.)

“This has dramatically changed the landscape,” Dr. Lowenkopf says. “We are able to treat many more patients in this extended time window and we are getting appropriate outcomes.”

With strokes, it pays to BEFAST

Even though there is now more time to treat the stroke, it’s still crucial to call 911 and get to the hospital as soon as possible, Dr. Lowenkopf stresses. “When a stroke is happening, 2 million brain cells are dying every minute. The chances that you will recover without disability are still based on recognizing symptoms and treating them.”

Because it’s important to know the signs of a stroke, Dr. Lowenkopf recommends using the acronym BEFAST to easily remember them:

Balance: The sudden onset of loss of balance

Eyes: A change in eyesight—blurred vision, double vision, loss of vision

Face: When you smile one side of the face does not move

Arms: The arm doesn’t move or it drifts when you try to move it

Speech: Trouble producing or understanding speech (for instance, slurring your words)

Time: If you see any of these symptoms, call 911. The key to effective stroke treatment is early symptom recognition and getting to a hospital where you can be treated.

Stroke hero - Grateful her boss knew the signs of stroke:

Even though this is an incredibly exciting time because many more stroke patients can be treated, Dr. Lowenkopf urges you to remember that “the best stroke is the one that never happens.”

“Most strokes can be prevented. Know what the risk factors are and if you do have risk factors work with your health care provider to make sure those risks are being addressed.”

The single most important risk factor for stroke is high blood pressure — Dr. Lowenkopf says the goal should be less than 130/85 most of the time. Smoking, heart disease and high cholesterol are all other risk factors that can be controlled with medication, a healthy diet and an active lifestyle. “If people controlled their blood pressure and other risk factors, there would be about 70 percent fewer strokes in the United States every year,” Dr. Lowenkopf says.

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Dan Pierce, MD at Providence St. Patrick Hospital - a primary stroke center in Missoula, Montana - talks about the TeleStroke system that allows for earlier diagnosis and treatment of stroke: