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Intravenous delivery of clot-busting drug still best intervention for ischemic stroke

April 16, 2007

American Heart Association/American Stroke Association Guidelines

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:

- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

- Sudden confusion, trouble speaking or understanding

- Sudden trouble seeing in one or both eyes

- Sudden trouble walking, dizziness, loss of balance or coordination

- Sudden, severe headache with no known cause

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:

- Hospitals should develop emergency stroke protocols so patients can be assessed and treated within 60 minutes of arrival in an emergency treatment center.

- More medical centers should seek certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.

- Patients should receive early and carefully chosen treatments for abnormal blood pressure, fever or abnormal blood sugar levels, which can negatively affect stroke outcome.

- Although clot-dissolving drugs other than tPA are being tested, none has been established as effective and they should only be given as part of a clinical trial.

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.

American Heart Association