Times have changed when it comes to treating a heart attack. No longer do patients sit in a dark room, grip their doctor’s hand and hope to survive like they did decades ago.
Successful clinical trials, technological advancements, changes in health care delivery, patient awareness and more effective guidelines have resulted in treatment options for even acute heart attacks. It is expected that patients will have a procedure 90 minutes from presenting to a hospital, survive the event and even live well beyond the incident.
Those suffering an ischemic stroke used to be in a similar hope-and-pray situation. But the last five years has brought promising new imaging tools, devices and treatment guidelines that served as the blueprint to more effectively treat what many referred to as a “brain attack.”
These advancements have put ischemic stroke treatment on a similar path to heart attack treatment — a good thing for the roughly 795,000 people who endure the condition each year. In the US, more than 18,000 ischemic strokes were treated with endovascular techniques in 2018, which is a 50-percent increase from 2014, thanks to these improvements.
It’s not nearly enough. But the needle is finally moving upward.
Though they are on similar courses, stroke is a bit different than heart attack. For a heart attack, you need an EKG, which will show the issue relatively quickly. Public education has now made it well known that if you have chest pain it is a heart attack until proven otherwise. If necessary, you will have a procedure done in a cardiac catheterization lab typically in an hour and a half.
Several issues — seizures, tumors, hypoglycemia — can mimic stroke, which makes it challenging to diagnose. It’s hard to determine where the blockage is without the appropriate tests. You need a CT scan to ensure it is not a bleeding type of stroke and maybe even more advanced imaging such as a CT angiogram or perfusion and lab tests, all of which extend diagnosis time when time is so critical to reversing the potential effects of a stroke.
For decades, clinical trials failed to establish new endovascular treatments for stroke. In early 2014 multiple trials were published that essentially showed no benefit for the newer treatments.
Fortunately, later a Dutch study called “Mr. Clean” was published in the New England Journal of Medicine. The study’s overwhelmingly positive results proved mechanical thrombectomy as a solution six hours after ischemic stroke symptoms begin. This was subsequently followed by several other large trials all showing an overwhelming benefit for mechanical thrombectomy.
The procedure uses reperfusion therapy (combining drugs and surgery) to restore blood flow through or around blockages. Reperfusion therapy is typically used for heart attacks as well.
“Mr. Clean” started one of the most powerful happenings in stroke care. The two most recent studies “Dawn” and “DEFUSE” added imaging and extended the time to perform thrombectomy in selected patients from six to 16 hours after the patient was last known to be well.
This was a complete turnaround, just like in the 1980s and 1990s when the Joint Commission and American Heart Association were determining door-to-needle times for percutaneous coronary intervention for heart attack.
Computed tomography (CT) perfusion has become the holy grail of stroke imaging, allowing radiologists to track blood flow in the brain. And there have been other developments improving the speed of care.
Software called RAPID processes these images and immediately sends them to the neuroendovascular surgeon, who can quickly identify whether a stroke has occurred. With RAPID, I get an email on my cellphone within minutes of the test and will know whether the patient is a mechanical thrombectomy candidate or not. RAPID reduces diagnosis time and is much faster, simpler and easier.
Viz.ai is another software that expedites diagnosis and synchronizes care. The mobile application uses CT angiography and AI to detect a large vessel blockage. It represents a HIPPA-compliant method of rapidly communicating diagnosis and additional information to the clinicians making decisions.
The American Stroke Association instituted Get With the Guidelines as a way to connect outcomes data and provide standards of care. There are now guidelines for stroke, heart failure and resuscitation.
In essence, the guidelines dictate the door-to-needle time to begin a mechanical thrombectomy. Patients coming from the street have 90 minutes to begin the procedure. Those transferring from another hospital have 60 minutes (assuming they had all imaging and labs done). In comparison, the door-to-balloon time for percutaneous coronary intervention for heart attack is also 90 minutes.
For stroke, the goal is to re-vascularize the tissue as quickly as possible. Two million neurons die every minute and the delay just increases the likelihood of a disability. Every 30 minutes without restored blood flow equates to a 10-percent decrease in a patient walking out of a hospital independently.
These guidelines and stroke care advances have been game-changing. But what else can be done?
Henry Woo, MD, is a neurosurgeon at Northwell’s Institute for Neurology and Neurosurgery. He specializes in open cerebrovascular and neuroendovascular surgery in the treatment of cerebral aneurysms, arteriovenous malformations, carotid artery and intracranial stenosis, stroke and subarachnoid hemorrhage.