New Ischemic Stroke Guidelines

guidelinesIschemic Stroke Guidelines released at the end of January 2013.

These guidelines were put together by an expert panel and touch on many aspects of acute stroke care, with a focus on ischemic stroke. The guidelines include dozens of recommendations. I am not going to talk about all of them today, but I would like to highlight some that are particularly important to treating clinicians.

First, the guidelines come out very strongly in favor of transporting patients with acute stroke to the nearest primary or comprehensive stroke center. This is a great idea because we know from numerous studies and analyses that care at these certified stroke centers really does make a difference in terms of improving outcomes and reducing complications. That is a very strong positive recommendation. In addition, the guidelines now say that these stroke centers should be certified by an independent body or agency, so we are moving away from the paradigm of self-certification [toward independent, objective certification], which is also a positive move.

Next is a curious recommendation about patients with intracranial stenosis: If you want to confirm that someone has an intracranial stenosis, the guidelines now recommend catheter angiography rather than noninvasive studies such as CTA (computerized tomographic angiography) or MRA (magnetic resonance angiography). That is curious, because I think a lot of folks have moved away from doing catheter angiography, but in these recommendations they really come down in favor of doing a catheter angiogram to confirm an intracranial stenosis. We will have to see where that goes in terms of altering routine care.

As you might imagine, a fairly extensive section [is dedicated to] using IV tPA (tissue plasminogen activator), and the recommendations come down very strongly in favor of a door-to-needle time of 60 minutes, which is emerging as a national quality metric by the National Quality Forum. This is a good timeframe to aim for, although, again, in a clinical context I think we have all had the experience or occasion when we do have to delay giving the IV tPA as we try to get more clinical information. I think we need to have some flexibility here. The new guidelines do recommend treatment up to the 4.5-hour time window, with exclusion criteria in terms of age, oral anticoagulation, diabetes, and stroke, similar to [the criteria in] the ECASS 3 study. What is curious is that if you talk to our stroke colleagues in Europe who actually conducted ECASS 3, they do not follow their own exclusion criteria. They treat everybody [with IV tPA] up to 4.5 hours except those who have had a massive stroke with significant early changes. Our new guidelines, the 2013 guidelines, do have the ECASS 3 exclusion criteria similar to what the scientific statement said several years ago. However, these new guidelines now say that it is reasonable to treat people with mild strokes, or improving symptoms, if the benefits outweigh the risks. They also say that it may be reasonable to treat patients even if they had surgery within the past 3 months, assuming that there is no active bleeding and the benefits outweigh the risks.

Finally, on the vexing issue of using IV tPA in patients taking [one of the] new oral anticoagulants, the guidelines say do not treat these patients with IV tPA unless you are sure that their clotting studies are normal or you are certain that they have not taken any of these oral anticoagulants for the past 2 days.

Dr. Mark Alberts is a Vice-Chair of Clinical Affairs in the Department of Neurology at University of Texas Southwestern Medical Center in Dallas.