Each day in the United States, strokes affect thousands of lives. Strokes can happen with little or no warning, and their effects can be devastating: Stroke is the leading cause of disability in the United States, and it is among the leading causes of death.
The majority of strokes are ischemic strokes, in which a blood clot blocks a part of the brain’s blood flow. Two excellent treatments are available for ischemic strokes: a clot-dissolving medication called tPA, and a clot-removing procedure called a mechanical thrombectomy. But both treatments must be delivered within a certain time frame—traditionally, just a handful of hours after the onset of the stroke.
Now there is incredible news of recently released research that extends the time frame for the effectiveness of both treatments. Studies published in the New England Journal of Medicine indicate that the window of time for administering tPA can be a third of the time longer than previously believed, while the window of time for clot removal can be up to four times longer.
“Previously we had a very short time, a matter of a few hours, from the onset of symptoms to the time we could perform a procedure that would help people,” says neurosurgeon and stroke expert Dr. Sean Lavine. “Now we know that we have longer, sometimes up to 24 hours, to help people return to a functional life.”
The advantages of this time extension are so significant that the new studies were cut short so that their results could be made public as quickly as possible. Stroke treatment guidelines from the American Heart Association/American Stroke Association have been updated to reflect the new information.
With this new set of guidelines, doctors will be able to use these lifesaving treatments to reach even more patients.
Now it’s a matter of putting the recommendations into practice. “We have to get the word out to the public and to first responders that these therapies are available, effective and can change a person’s outcome from stroke,” says Dr. Lavine.
The first step to rapid treatment is helping people recognize a stroke. Dr. Lavine suggests that people use an acronym to help them recognize a stroke and remember that when stroke happens, “Act FAST.”
F: Face. Ask the person to smile. Does one side of the face droop?
A: Arms. Ask the person to raise both arms. Is one, or both, too weak to fully raise?
S: Speech. Ask the person to repeat a simple sentence (“Today is Monday” or something similar). Does the person have difficulty producing the sentence?
T: Time. Don’t delay. If the answer to any question is yes, call 911.
Time is still critical. The new recommendations mean that for some patients, treatment can make a difference for much longer than previously believed. But still, for many patients, the earlier the treatment, the bigger the difference.
Patients who could benefit from tPA (the clot-dissolving drug) or mechanical thrombectomy (the clot-removal procedure) must be quickly connected with facilities that can provide those treatments. Unfortunately, connecting the right patients with the right facilities isn’t always as simple as it sounds.
The first hurdle is identifying those patients who can be helped by these treatments. Generally an CT scan or MRI is required to make this determination. For either tPA or thrombectomy to be useful, the patient’s stroke must be ischemic (caused by a clot), not hemorrhagic (caused by bleeding).
To benefit from mechanical thrombectomy, the patient’s clot must be in a larger vessel. For either treatment, there must be a certain pattern of damage to the brain tissue: The area of tissue that is already damaged beyond repair must be surrounded by threatened brain tissue that could still be saved. This surrounding area is called the penumbra. It gets some blood flow from nearby vessels, and if blood flow is restored in the blocked vessel, tissue in the penumbra may make a good recovery.
The second hurdle is connecting such patients with the right facilities. This is not too difficult with the clot-busting drug tPA, which is straightforward to administer with an intra-venous or IV line. Neurologists and some emergency physicians at many facilities can typically perform this potentially lifesaving treatment. The main concern is doing this as quickly as possible. Since tPA was introduced in the 1990s, ever-greater efforts have been made to reduce “door-to-needle” time—the time that elapses between a patient’s arrival at the hospital and the drug’s administration. Columbia even has a stroke treatment ambulance that makes door-to-needle time a thing of the past.
In this ambulance, first responders can perform an emergency CT scan and administer tPA en route to the hospital. Mechanical thrombectomy, however, is available only at major “comprehensive stroke centers” or “thrombectomy-capable stroke centers” like Columbia University Medical Center/NewYork-Presbyterian Hospital. Comprehensive stroke centers have teams of highly trained experts on call to treat any kind of stroke (ischemic or hemorrhagic), any time of day or night. These stroke specialists must undergo years of training, must have access to the most up-to-date technology and must be available around the clock at a moment’s notice.
Dr. Lavine hopes to educate families and first responders to seek out comprehensive stroke centers for patients who may be having a stroke. As part of the stroke team at CUMC/NYPH, Dr. Lavine has seen again and again how a patient’s life can be changed by receiving the right treatment in the right time. In some cases, it can mean the difference between walking away from the stroke and suffering disability or even death.
Dr. Lavine’s specialty is treating stroke using mechanical thrombectomy and other procedures performed from within blood vessels. (As a group, procedures performed from within blood vessels are called endovascular procedures.)
To perform a mechanical thrombectomy, Dr. Lavine guides tiny instruments through the body’s vessel system. A delicate wire cage called a stent retriever “grabs” the clot, then Dr. Lavine removes clot and cage together. He can also perform endovascular suction thrombectomy removal of intra-cranial blood clots and also delivery of tPA—putting the drug right where it’s needed at the clot—and other endovascular procedures available only from specialists like himself at comprehensive and thrombectomy-capable stroke centers.
Sometimes, however, when a person has a stroke, no comprehensive stroke center is nearby. In such cases, a patient could receive an MRI or CT scan and tPA at the closest facility. Then, if warranted, the patient could quickly be transferred to a comprehensive stroke center. Time is still of the essence, so coordination among hospitals and agencies will be crucial to pushing forward the best practices in stroke treatment.
In an effort to educate the public on these and other important points, Dr. Lavine hosted a Facebook Live event recently. He described the different types of stroke, explained how to identify a stroke and answered questions from viewers. The event was recorded, and you can watch it here.
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