New Stroke Guidelines Coming

The Society of NeuroInterventional Surgery plans to issue new guidelines for treatment of ischemic stroke, its president-elect said.

Donald Frei, MD, a Denver-based neurointerventional surgeon, said that based on the overwhelmingly positive results of 3 newly reported studies, intravascular thrombectomy is the best treatment for many patients with major ischemic strokes.

“We will publish new guidelines within a few weeks,” Frei said. He expects the American Heart Association and the American Stroke Association to also update their guidelines.

The studies, ESCAPE, EXTEND-IA and SWIFT PRIME,were presented at the AHA/ASA’s International Stroke Conference in Nashville, Tenn. last week. All showed that people who have ischemic strokes caused by a large vessel blockage will have much better results if the clot is quickly removed mechanically vs. receiving intravenous tPA without the intervention.

The endovascular intervention reduces stroke mortality by 50%, Frei said.

Because of the success of the studies, Frei expects major shifts in patient care.

In the pre-hospital realm, ambulance crews should be directed to take stroke patients to comprehensive stroke centers, which have the expertise and equipment needed to perform the interventions. That may mean bypassing lesser stroke centers where patients get only tPA treatment, the so-called “drip and ship” approach.

The new studies showed that the window for successful reperfusion closes quickly. Since 2 million neurons die every minute the brain tissue is cut off from getting oxygenated blood, seconds count.

“With the type of evidence we now have, it’s worth driving the extra miles,” Frei said.

In a perfect world, all comprehensive stroke centers would have mobile stroke unit ambulances like one displayed at the conference. The vehicles are equipped with CT-scanners, so crews can relay brain images to telemetry physicians to determine the nature of a patient’s stroke. "I'd love to have one," Frei said.

But even if a changed emergency medical services protocol results in patients who are not candidates for clot retrieval being taken to a comprehensive stroke center, there is no harm done, Frei said. Such centers are unlikely to be overwhelmed, and the patients with lesser strokes (or whose strokes are too serious to be treated by the intervention) can still be triaged within the hospital.

Hospitals that offer stroke care but not the endovascular intervention may have to send candidates by Medivac helicopter.

From a national perspective, offering endovascular treatment to all will be costly, he agreed, but not so expensive as the care disabled stroke patients need.

The findings of the 3 recent trials, building on MR CLEAN the Dutch research reported in December, 2014, upended studies published in 2013 that found stroke patients did not improve more with mechanical interventions than with clot-dissolving drugs alone.

Frei said he believes those earlier findings were due to patients being treated by less experienced operators at low-volume centers, and because clot-retrieval instruments were inferior to those now available.

“The old devices weren’t able to open a vessel as quickly or completely,” Frei said, with recanalization rates of 40% vs. the 100% rate of today’s instruments.

But the same patient-selection criteria were used in all studies, he said.

Frei attended just 1 day of the 3-day stroke conference, just to be there to hear the studies presented.

“It was the first time I have ever heard scientific presentations interrupted by applause,” Frei said, a measure of how excited and vindicated these specialists are to get confirmation the interventional approach works.

Then he flew back to Denver, Colo. where he had patients waiting. “I did several procedures that same afternoon,” he said, “When I see these stroke patients able to walk out of the hospital I’m ecstatic.”