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Building New Systems for Stroke Care

ACPH logoHow Should Hospitals Respond to Updated AHA Guidelines on Endovascular Therapy For Stroke?

New findings about stroke therapy prompted the American Heart Association to update its clinical guidelines late last year. The AHA/ASA called for hospitals to develop regional networks to ensure that qualifying stroke patients have rapid access to endovascular therapy following severe stroke. Some larger hospitals already have such systems in place but putting the necessary infrastructure in place will be a challenge for many smaller community hospitals.

I reported on the development for ACP Hospitalist magazine. Following is an excerpt from that article, in which I interviewed leading stroke care experts about how hospitals should respond to the new guidelines. They provide some important insight into the logistical and cost implications of delivering this type of care.

You can read the full article on the ACP Hospitalst website, but here are some of key points:

  • The updated guidelines are based on 5 studies—MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT. While earlier trials had failed to report any significant benefit of ET over standard care with intravenous tPA, these studies achieved betteStroke image MRIr results by using advanced imaging to select patients and retrievable stents to remove clots.
  • The studies emphasize the importance of using advanced imaging techniques, including CT angiography (CTA) and magnetic resonance angiography (MRA), in the initial assessment of stroke patients. The tests provide a more detailed view of blood vessels than non-contrast CT, allowing physicians to assess whether a patient has enough salvageable brain tissue to benefit from reperfusion.
  • Timing is tricky: According to David Likosky, MD, director of the stroke and neurohospitalist programs at EvergreenHealth Medical Center in Kirkland, Wash.: “You have to be careful not to divert patients too far away, considering that the bulk of patients are not candidates for endovascular therapy and would benefit more from faster access to IV tPA. At the same time, picking the right patients for ET and transporting them as quickly as possible has huge potential benefit.”
  • Strategies being developed at stroke centers include: Telemedicine units that link ambulances with ED physicians via television monitors (see this recent study in JAMA Neurology); mobile stroke units  with advanced imaging and a specialist on board (see my previous article that discusses this model); Telestroke networks where specialists at major stroke centers assist ED physicians at a network of smaller hospitals in evaluating stroke patients via telemedicine connections.
  • Continue to prioritize tPA: “All patients with ischemic stroke should get tPA while you are making plans about whether they also need embolectomy,” says S. Andrew Josephson, MD, medical director of inpatient neurology and head of the neurohospitalist program at the University of California San Francisco. “The best way to maximize resources and minimize transfers is for all hospitals to also perform rapid vessel imaging to identify patients who might be eligible for endovascular therapy.”
  • The new emphasis on endovascular care is likely to increase demand for hospitalists at both smaller and larger centers.
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