Intravenous delivery of an approved clot-busting drug remains the most beneficial proven intervention for ischemic stroke, according to updated American Heart Association/American Stroke Association guidelines published in Stroke: Journal of the American Heart Association.
The Guidelines for the Early Management of Adults with Ischemic Stroke also indicate that new options -- such as intra-arterial administration of clot-busting drugs and mechanical removal of blood clots -- show promise.
The guidelines focus on the crucial first hours from the time an ischemic stroke occurs through emergency evaluation and treatment in a hospital. Ischemic strokes, the most common type of stroke, are caused by a clot that blocks blood flow in an artery to the brain.
The panel emphasized the importance of public education on the symptoms of stroke, which include:
Patients or observers should call 9-1-1 when stroke symptoms first develop.
"We are pushing for the fastest possible treatment because 'time is brain.' For every minute that goes by, the likelihood of a poorer outcome increases," said Harold P. Adams, Jr., M.D., chairman of the writing group.
Intravenous delivery of the clot-busting drug tissue plasminogen activator (tPA) is only approved to be used within three hours of symptom onset.
The panel said other techniques -- mechanical devices and intra-arterial administration (IA) of tPA -- are becoming more widely available and should be considered for patients with moderate-to-severe strokes who arrive at the hospital too late to receive intravenous tPA. However, information on these techniques is limited and more research is needed.
The new guidelines suggest emergency medical personnel perform a quick stroke assessment, draw blood and alert the hospital that a patient with a suspected stroke is coming. Patients should also be transported to the nearest "appropriate" hospital for emergency stroke care even if that means bypassing the closest facility or calling for air evacuation.
"Appropriate" facilities are those with the expertise and resources to provide modern emergency stroke care. Regional plans for paramedics to bypass institutions that do not have emergency stroke care should be developed, according to the guidelines.
The updated guidelines are an extensive revision of those issued in 2003 and 2005. Among the new or revised recommendations:
For the first time, the association has included comments about palliative or comfort care of a patient with a devastating brain injury.
"We included this in the document so that physicians may recognize that they can take measures to not prolong suffering or dying in a patient whose extensive brain injury will result in a fatal outcome," Adams said.
Co-authors are Gregory del Zoppo, M.D., vice chair; Mark J. Alberts, M.D.; Deepak L. Bhatt, M.D.; Anthony Furlan, M.D.; Robert L. Grubb, M.D.; Randy Higashida, M.D.; Edward C. Jauch, M.D.; Chelsea Kidwell, M.D.; Pat Lyden, M.D.; Lewis B. Morgenstern, M.D.; Adnan I. Qureshi, M.D.; Robert H. Rosenwasser, M.D.; Phillip A. Scott, M.D.; Eelco F.M. Wijdicks, M.D. and Lawrence Brass, M.D. (deceased).
Materials provided by American Heart Association. Note: Content may be edited for style and length.
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