Stroke Month | Management of Acute Ischemic Stroke: A new era has dawned
By David B. Wheeler, M.D., Ph.D., F.A.A.N. May 4, 2016
The past five years have seen unprecedented advances in acute stroke management. With more aggressive treatment parameters, revolutionary changes in interventional techniques and improvement in the organization of care, more and more people are walking away from stroke with little to no deficit. The next five years of stroke care will focus on improving systems of care for stroke with the goal of making this care available to every person in Wyoming.
Since the approval of tissue plasminogen activator (tPA) in 1995, there have been ongoing studies of the safety and efficacy of this clot-buster in the treatment of acute ischemic stroke. These studies demonstrated that tPA could be given safely with the same expected benefits up to 4 to 12 hours after symptom onset. In 2013, the American Stroke Association and other organizations recommended that tPA be considered for this extended time window in patients without prior stroke and diabetes and who were less than 80 years old. In 2014, the FDA approved updated labeling for tPA to say that the medication should be avoided only in “situations in which the risk of bleeding is greater than the potential benefit.” This relaxation of exclusion criteria meant, for example, that seizure at onset and history of intracerebral hemorrhages are no longer contraindications to giving tPA. These changes have dramatically increased the fraction of stroke patients who are eligible for clot-busting treatment.
2015 saw the publication of several landmark studies that have completely changed the way stroke care is delivered. New endovascular techniques are so effective that that the American Stroke Association has concluded:
- “Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke. Systems of care should be organized to facilitate the delivery of this care.” (Stroke. 2015;46: 3024-3039)
These results, taken together with relaxed exclusion criteria, lead to the following firm recommendations based on the highest level of evidence:
- Patients presenting with acute stroke should receive IV tPA up to 4.5 hours after onset and,
- Patients with stenosis of the proximal MCA or ACA should undergo stent retrieval up to 6 hours after onset.
If we are to meet these goals and deliver the same care to every person in Wyoming we must improve our system of care.
Systems of care have dramatically reduced the rate of death and disability after stroke. Wyoming Medical Center is committed to a systems approach to stroke, and as a result, we are a certified Primary Stroke Center and have been awarded the highest standards of excellence by the American Heart Association for the stroke care we deliver. Our mission going forward is to enable hospitals and providers across the state to deliver the same level of care.
But, none of us can do this alone.
We are encouraging increased cooperation amongst the state’s health care facilities to integrate stroke services – from activation of Emergency Medical Services, through the rehabilitation process (if it is even needed). We are working closely with the state Department of Health to create rules that will ensure stroke patients are efficiently transported to the most appropriate facility; one that is equipped and ready to deliver tPA rapidly and safely. To that end, we strongly encourage participation in programs like the Joint Commission’s Acute Stroke Ready Hospital certification. Our stroke team is eager to work with you and your hospitals because together we can make sure that every person in Wyoming has a chance to walk away from a stroke.
'LIKE A MIRACLE'
Douglas woman Rebecca Renstrom used to think a stroke meant suffering through life-long deficits. But when she walked out of Wyoming Medical Center 2 1/2 days after hers, her family members couldn't even tell she'd had a stroke.
“I think the most amazing thing about this case is how well our system of care worked,” said David Wheeler, M.D., Ph.D. “Mrs. Renstrom’s case represents the culmination of a decade of work putting a system in place.”
Read full story here.
Dr. Wheeler is board certified in neurology and clinical neurophysiology. He is a Rhodes Scholar and was the 2010 Wyoming Medical Center Physician of the Year. He serves on the boards for Wyoming Medical Center, Wyoming Dementia Care and the Wyoming Medical Society. He is also director of the Wyoming Epilepsy Center and the Primary Stroke Center at WMC. He practices at Wyoming Neurologic Associates, 1020 E. Second St., Suite 100, in Casper. For a referral or an appointment, call (855) 39-BRAIN, or email him at firstname.lastname@example.org.