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Even With New Stroke Guidelines, Minutes Still Matter

Dr. E. Sander Connolly has an important reminder about the new stroke treatment guidelines for neurosurgeons and the general public:

When it comes to stroke treatment, minutes still matter.

In an article in the journal Neurosurgery, Dr. Connolly and his co-authors* describe incredible recent research in stroke treatment. Studies given names like DAWN, EXTEND-IA and DEFUSE-3 have examined a treatment called mechanical thrombectomy. In this treatment, the blood clot, or thrombus, causing a stroke is removed mechanically, using tiny instruments that are passed through a patient’s blood vessels.

The studies revealed that mechanical thrombectomy help patients recover from a stroke, even if performed much longer after a stroke than doctors had previously believed possible.

Brain tissue is sensitive to oxygen loss. That’s why minutes matter in stroke treatment. When a blood clot blocks blood flow to the brain, removing that clot quickly is of the utmost importance. The time window during which mechanical thrombectomy is effective was believed to be only six hours. But these studies reveal that in some cases, doctors have up to eight or even 24 hours to help a patient who has had a stroke. For patients who fit a set of criteria, this extension of the useful treatment time frame may actually mean the difference between permanent disability and a full recovery. (Read more about this amazing research and the new guidelines for stroke treatment here.)

But this incredible extension applies to only a small number of stroke patients. Patients must have had a certain type of stroke, in a certain size of blood vessel, and also must possess an area of threatened brain tissue that is still receiving some blood supply from other vessels. It is this tissue, called penumbral tissue, that may recover even if blood flow is restored as much as 24 hours later.

Not all stroke patients fit this bill. A CAT scan is generally required to determine what treatment will be most effective for any given patient, and over what time frame. That’s why the minutes still matter. Evaluating and treating all stroke patients quickly, and rapidly transferring them to a Comprehensive Stroke Center (like Columbia University Irving Medical Center/NewYork-Presbyterian Hospital) if necessary, is key.

“[I]t is still imperative that wide-scale improvements in symptom-onset-to-intervention times be implemented to improve stroke outcomes for a larger portion of the population,” write the authors. In other words, even given the new guidelines, we need stroke treatment systems that ensure all patients are treated as rapidly as possible.

One solution is an emergency service like the Mobile Stroke Treatment Unit (MSTU) now in use through CUIMC/NYPH, Weill Cornell and the New York City Fire Department. This is a vehicle that is basically an enhanced ambulance. It is staffed with specially trained experts and equipped with tools including a CT scanner. The clot-busting drug tPA can be started right there in the MSTU. The patient’s CT scan can be sent ahead to the hospital so that doctors and staff can be ready to treat the patient the moment she arrives.

The MSTU has been a great success. But to help the greatest number of stroke patients, other systems must also be optimized, in the New York area and in all other parts of the country. In more rural areas, for example, using stroke-diagnosing technologies via mobile phone apps may be a very promising method of speeding treatment. (Read more about these in the recent Wall Street Journal article here.) These innovations and systemic improvements are critical, because when it comes to stroke, minutes matter.

Dr. Connolly’s colleague Dr. Philip Meyers couldn’t agree more. As part of the Guidelines Committee for the Society of NeuroInterventional Surgery, he helped develop recommendations for the best ways to connect patients with the right stroke care for them, the most quickly. The group published its guidelines in the Journal of NeuroInterventional Surgery—read our blog post about that here.

It’s an exciting new age for stroke treatment. Mechanical thrombectomy and tPA have enabled doctors to help an unprecedented number of stroke patients. And now we know that in some cases, doctors have even longer to deliver the treatments that can save lives. And we will keep working to improve stroke treatment systems and act fast to help stroke patients.

Read more about Dr. Connolly on his bio page here.
Read more about Dr. Meyers on his bio page here.

* Full list of authors: Robert M. Starke, M.D., M.Sc.; David McCarthy, B.S.; Ricardo J. Komotar, M.D.; E. Sander Connolly, M.D.

patient journey

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