2018 AHA/ASA Guidelines Support Stroke Systems of Care, Telemedicine, and Expanded Therapy Window
January 24, 2018—The American Heart Association/American Stroke Association (AHA/ASA) announced the publication of the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. The document by William J. Powers, MD, et al is available online in Stroke. The guidelines were released during ASA's International Stroke Conference 2018 held January 24–26 in Los Angeles, California.
The AHA/ASA advised that the guidelines are based on a review of over 400 peer-reviewed published studies that were examined by a group of experts in stroke care and are the most comprehensive recommendations for treating ischemic stroke issued since 2013.
In comments to Endovascular Today, Justin F. Fraser, MD, FAANS, FAHA, emphasized the importance of the new style of guidelines introduced in 2018. Acknowledging the hard work of the writing group in attempting to address topics across every major aspect of acute ischemic stroke treatment—from early recognition and diagnosis in the field and through rehabilitation—Dr. Fraser believes that the guidelines represent a comprehensive, exhaustive assessment of evidence-based decision-making. It is important, he noted, that practitioners carefully review the evidence-based statements and key details provided in the summaries for each guideline. Dr. Fraser is Associate Professor of Cerebrovascular, Endovascular, and Skull Base Surgery and Director of Cerebrovascular Surgery at the University of Kentucky in Lexington, Kentucky.
A major new recommendation in the guidelines increases the window of time for selected patients who are eligible for mechanical thrombectomy in large vessel occlusions. This guideline recommends that large vessel strokes can safely be treated with mechanical thrombectomy up to 16 hours after a stroke in selected patients. Under certain conditions, based on advanced brain imaging, some patients may have up to 24 hours. The previous time limit was 6 hours.
"The expanded time window for mechanical thrombectomy for appropriate patients will allow us to help more patients lower their risk of disability from stroke," commented Dr. Powers, who is the Writing Group Chair for the guidelines, in the announcement. "That's a big deal. That's potentially a lot more people who could benefit, and it has completely changed the landscape of acute stroke treatment." Dr. Powers is Professor of Neurology at the University of North Carolina in Chapel Hill, North Carolina.
Dr. Fraser concurred, stating, "The new AHA/ASA guidelines support the recent trials extending the time windows for mechanical thrombectomy. In properly selected patients, mechanical thrombectomy represents one of the most effective treatments in all of medicine. These new guidelines will have profound effects, as they will open the door to many patients undergoing thrombectomy."
Further, Dr. Fraser believes the guidelines will likely evoke more standardization of stroke care among stroke centers, as well as likely increase the volume of thrombectomies performed, as more patients are now candidates.
In a related development, in conjunction with the Joint Commission, the AHA/ASA has created a new level of hospital certification for thrombectomy-capable stroke centers to identify hospitals that meet rigorous standards for performing mechanical endovascular thrombectomy.
The AHA/ASA advised that another new recommendation broadens the eligibility for administering intravenous (IV) alteplase, a tissue plasminogen activator (tPA) that is the only US Food and Drug Administration–approved thrombolysis treatment for ischemic stroke. Previously, patients with mild strokes were not eligible for this treatment, but new research suggests that it could help some of these patients. The guideline advises that doctors should weigh the risks and benefits in individual patients, as the drug can decrease disability when given promptly and appropriately. Dr. Powers noted, "It potentially increases the number of people getting IV clot-busting treatment."
An unchanged but important guideline recommendation is the need for fast action when a person shows the symptoms of a stroke. The AHA/ASA's public awareness message on how to recognize a stroke includes the "FAST" acronym (Face drooping, Arm weakness, Speech difficulty, Time to call 911).
Dr. Powers stated, "It's better to call 911 than to have somebody drive a stroke patient to the hospital. Hospitals are set up to immediately treat acute stroke patients arriving by ambulance. In many patients, getting to the hospital quickly is the difference between living a life of disability or one free of disability from stroke." For hospitals that do not have access to neurologists or emergency department doctors trained to use the clot-dissolving medication, the guidelines recommend connecting those hospitals to stroke experts in real time via videoconferencing. Research has shown that this telestroke approach received the same quality of care as they would have at stroke centers with a neurologist on call, noted Dr. Powers in the AHA/ASA press release.
In summary, the guidelines include prehospital, urgent, and emergent treatment and address and include IV and intra-arterial therapy and in-hospital management, including secondary stroke prevention measures in the first 2 weeks after stroke. Implementation of regional stroke systems is supported.
The following strong recommendations with level A evidence are new: development of regional stroke care systems, quality improvement projects for emergency department personnel, multidisciplinary teams to increase safety of IV thrombolytic treatment, use of teleradiology for rapid diagnosis, and participation in stroke data repositories. Mechanical thrombectomy with the goal of reperfusion is recommended for patients who meet specific criteria and can be initiated within 6 to 16 hours of symptom onset.
In addition, it is recommended that multimodal CT and MRI—including after perfusion imaging—should not delay the administration of IV alteplase, the CT hyperdense sign should not be used as a criterion for withholding alteplase therapy, and sonothrombosis should not be used as adjuvent therapy with IV alteplase.
Most new evidence for the guidelines was previously incorporated into focused updates, scientific statements, and published guidelines since 2013. These new guidelines are comprehensive and an updated incorporation of those more recent publications.
Also in Stroke, Eric E. Smith, MD, et al published systematic reviews for the 2018 guidelines on accuracy in prediction of diagnosing large vessel occlusion in adults with suspected stroke and the effect of dysphagia screening strategies on outcomes for patients after acute ischemic stroke.