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A Path to Get Ahead of Stroke
An initiative is underway to ensure patients with severe stroke receive prompt endovascular therapy.
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This is a “flip-the-switch” moment for stroke care. Endovascular treatment has been shown through major trials, conducted on a worldwide platform, to have an amazing benefit. The benefits of the latest generation of endovascular thrombectomy devices have been publicized well recently.
In MR CLEAN and other studies, patients with severe stroke due to emergent large vessel occlusion had better outcomes if treated with an endovascular thrombectomy device after IV tissue plasminogen activator administration compared with tissue plasminogen activator administration alone.
What has been less publicized is how these findings must fundamentally transform the way in which care providers manage patients with acute stroke from the first onset of symptoms. The Society of NeuroInterventional Surgery (SNIS) is attempting to raise awareness about this via its Get Ahead of Stroke campaign.
Goal to Raise Awareness
The Get Ahead of Stroke campaign seeks to bring change to stroke systems of care so endovascular treatment becomes the standard of care for large vessel occlusions in the severe stroke population. This is a message that needs to be conveyed not only to the public, but to the clinician community who are the first to diagnose patients including EMS and ED personnel, and neurology.
Trials including MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT and SWIFT PRIME proved that a strategy involving prompt endovascular thrombectomy was the best care for patients with stroke resulting from a large vessel occlusion.
We want to enhance public awareness of these findings, so that the topic of where to go in one’s area to have the appropriate care delivered can be a dinnertime conversation. Do people know where a neurointerventional-ready center is?
Crucially, the success of endovascular treatment of stroke is dependent on how soon after symptom onset it can be performed. One analysis in the Journal of NeuroInterventional Surgery found patients who had to be transferred to a center with endovascular thrombectomy capabilities had much slower time to revascularization compared with patients transported directly to such a center. In patients who had mechanical thrombectomy alone, median alarm-to-revascularization times were 75 minutes longer in those who had to be transferred (P = .0001), and in patients who had mechanical thrombectomy and IV tissue plasminogen activator, median alarm-to-revascularization times were 99 minutes longer in those who had to be transferred (P < .0001).
System Implementation
The goal of the SNIS is to improve systems of care from the ground up across the country by working with state legislatures and public health officials to pass guidelines that will enable patients with large vessel occlusion to be taken directly to the nearest neurointerventional-ready center.
On a state-by-state basis — in collaboration with our partners across the EMS, patient advocacy, medical spectrum — we’re figuring out what protocols need to be in place so that transport to the right facility can happen (after an educated diagnosis on stroke severity). What systems of care and workflow need to be in place for that to happen?
Similar to the STEMI system of care, which involved changing diagnosis, transport and treatment protocols to make it better for patients, policymakers and officials should begin thinking about stroke as the time-critical diagnosis that it is. EMS should be empowered to bring patients with severe stroke to the closest neurointerventional facility where those patients can receive the definitive care they need.
This is not a one-size-fits-all solution. What works for Rhode Island (and Rhode Island has an excellent system of care) might not work for Montana. The protocols for large metropolitan centers such as Chicago or New York are going to be quite different compared with where I am in Chattanooga, Tennessee, a smaller city that serves a large geographic area. Geography, population density and the proximity of neurointerventional-ready facilities must all be taken into account.
Appropriate Screening
Key to this effort is the appropriate use of stroke screening tools. These tools are being modified to identify patients with an emergent large vessel occlusion. We can then put the tools in the hands of EMS technicians and tell them that if this rapid assessment of the patient is done and the criteria for emergent large vessel occlusion are met, then that patient should go for the advanced imaging screening at an endovascular-capable center.
Currently, states are using different tools, and we’re collecting the data on how those perform, in hopes of working toward a decision on what is the best tool to give to EMS technicians. That is a work in progress, but it is an important part of the initiative.
The next step will be to determine the common pieces that must be in place to deliver the appropriate care and help all the states develop legislation that prioritizes patient outcomes. Then we can address the fundamental steps that we need to implement the campaign, and determine how that works best in each state.
‘Time Is Brain’
People need to know that if they suspect a stroke, they must call 911, activate EMS, and have their loved one evaluated and screened for a large vessel occlusion. If the medical community can have its workflow and systems of care realign, those patients will get direct access to endovascular treatment as quickly as possible without experiencing transfer delays. This will give them a better chance of good outcomes.
At the end of the day, we are racing a clock.
- References:
- Berkhemer OA, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1411587.
- Campbell BCV, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1414792.
- Froehler M, et al. J Neurointervent Surg. 2016;doi:10.1136/neurintsurg-2016-012589.24.
- Goyal M, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1414905.
- Jovin TG, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1503780.
- Saver JA, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1415061.
- For more information:
- Blaise Baxter, MD, FRCPC, is chief of radiology at Erlanger Health System, Chattanooga, Tennessee, and president-elect of the Society of NeuroInterventional Surgery. He can be reached at 975 E. Third St., Box 376, Chattanooga, TN 37403; email: blaise@tiiarad.com.
Disclosure: Baxter reports consulting and speaking for Medtronic, Penumbra and Stryker Neurovascular.