In "Guidelines for the Early Management of Patients With Ischemic Stroke," the American Stroke Association, a division of the American Heart Association, notes that researchers have investigated several promising new treatments for ischemic stroke.
Ischemic strokes, the most common type of strokes, are caused by a blood clot blocking blood flow to the brain. Giving tissue plasminogen activator (tPA) within three hours of stroke onset is the only U.S. Food and Drug Administration-approved treatment for ischemic stroke. The drug has been shown to reduce the effects of stroke and the chance of permanent disability.
"One of the key messages in the new guidelines is the importance of early treatment of stroke," says Harold P. Adams, Jr., M.D., chair of the panel that wrote the guidelines and professor of neurology at the University of Iowa Carver College of Medicine in Iowa City. "Public awareness of the symptoms of stroke and seeking medical attention immediately are critical to early treatment. Beyond that, all components of the health care system including physicians, hospitals, and emergency medical services need to treat stroke as the emergency it is."
The updated guidelines are a revision of association statements and supplements written in 1994 and 1996. In 2000, the Emergency Cardiovascular Care Committee of the American Heart Association outlined emergency medical services management of stroke and also recommended tPA.
This statement, aimed at primary care physicians, emergency medicine physicians, neurologists, and others who provide acute stroke care from hospital admission through the first 48 hours, discusses how to manage the neurological and medical problems that can complicate patient recovery.
"It was time to review the state of acute stroke care. Considerable research in stroke has been done in the last decade, and the guidelines for physicians need to reflect the new information," Adams says.
Some of the recent research has investigated neuroprotective agents to prevent stroke damage, methods to induce hypothermia to reduce fever and prevent stroke damage, other clot busting drugs and techniques, imaging techniques to diagnose ischemic stroke and surgical interventions.
While the advances are considerable, Adams says, "much additional work needs to be done. In this statement, we re-emphasize the potential use of tPA within three hours of ischemic stroke onset."
Among their recommendations, the panel notes:
- A regional or local organized program to expedite stroke care can increase the number of patients treated with tPA.
- Because time is critical in acute stroke care, institutions should have diagnostic equipment and staff available 24 hours a day, seven days a week or consider transferring stroke patients to a better-equipped facility.
- To date, no other clot-busting agent has been established as a safe and effective alternative to tPA.
- Intra-arterial thrombolytic therapy – a catheter-based treatment that delivers a clot-dissolving drug to the precise location of the brain blockage up to six hours after symptom onset – holds promise for some strokes, but its effectiveness has not been established.
- Aspirin may be given within 48 hours of stroke onset for most patients, but not within 24 hours of treatment with tPA. It has a modest benefit, but it should not be considered as an alternative to tPA for treatment of acutely ill patients.
- No medication with neuroprotective effects has been shown to be useful for ischemic stroke patients.
- Stroke units, including comprehensive rehabilitation services, and specialized stroke treatment centers should be developed.
- Steps should be taken to prevent additional strokes, and rehabilitation plans are an important part of acute care.
- Anticoagulants, such as heparin, are not indicated for most ischemic stroke patients.
"In the previous guidelines, we concluded that the data were insufficient to make any recommendation about the use of anticoagulants," Adams says. "Since then, several trials have tested the potential use of anticoagulants for early treatment of patients with stroke – and had negative results."
Co-authors are Robert J. Adams, M.D.; Thomas Brott, M.D.; Gregory J. del Zoppo, M.D.; Anthony Furlan, M.D.; Larry B. Goldstein, M.D.; Robert L. Grubb, M.D.; Randall Higashida, M.D.; Chelsea Kidwell, M.D.; Thomas G. Kwiatkowski, M.D.; John R. Marler, M.D.; and George J. Hademenos, Ph.D.
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