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New research showing the clear superiority of intra-arterial interventions over IV tissue plasminogen activator (tPA) in stroke patients with large vessel occlusions has created a mandate to upgrade stroke care, as well as an urgent need for integrated regionalized stroke care networks, according to three experts.
The , published several months ago, along with four other recent interventionalist studies, all showed better outcomes with thrombectomy and/or intra-arterial thrombolytic administration when compared with IV tPA in stroke patients with large occlusions, wrote , and in a editorial.
Caplan is from Beth Israel Deaconess Medical Center in Boston, while Furlan is from the University Hospitals Case Medical Center in Cleveland and Hacke is from Heidelberg University in Germany.
In contrast to earlier CT scan-only studies, these trials required more brain and vascular imaging to define, "the presence, sites and extent" of intracranial arterial occlusions as well as the extent of tissue damage and collateral circulation, they pointed out.
"The thrombectomy studies have created an ethical and practical mandate to upgrade stroke care," they wrote..."This mandate will require changes in systems of stroke care delivery at all levels of care. More stroke physicians, interventionalists, and neurologists are needed and this will require planning at a medical-school level and in residency training programs."
They called for algorithms to help direct emergency medical services (EMS) transport personnel on where to take patients, adding that these decisions should be routinely facilitated by telemedicine networks connecting transport personnel to stroke centers.
Patients suspected of having a stroke should be transported to an accredited comprehensive stroke center (CSC) when it is reasonable to do so, they wrote. When a CSC is too far away, patients should be taken to the nearest primary stroke center (PSC) that is linked to a CSC by telemedicine.
They also called for the expansion of telemedicine networks linking smaller, non-PSC hospitals in very rural communities to accredited stroke centers.
"The qualifications for these PSCs and CSCs should be upgraded so that imaging technology and the availability of neurologists to see patients 24/7 should be requisites," the editorialists wrote. "Systems for rapid imaging and throughput should be in place at these centers."
They added that outdated guidelines still in place for IV tPA administration are in need of extensive modification, "with few exclusions," and they called for reassessment of the role of CSCs.
"The CSCs are more than just hubs for thrombectomy," they wrote. "They will need to be redefined, which includes minimum numbers of advanced treatments. The CSCs should have interventionalists trained to treat patients with subarachnoid hemorrhage, aneurysms, and arteriovenous malformations as well as neurosurgeons who can perform emergency surgery for vascular patients."
From the American Heart Association:
Disclosures
The researchers disclosed no relevant relationships with industry.
Primary Source
JAMA Neurology
Caplan LR, et al "Acute ischemic stroke therapy: the way forward" JAMA Neurol 2015.