Letter by Avasarala Regarding Article, “2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”
To the Editor:
The 2015 American Heart Association/American Stroke Association update of the 2013 guidelines by Powers et al1 for the early management of patients with acute ischemic stroke using endovascular techniques make note of the recent, rapid evolution in the treatment options for stroke.
In the Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA) study,2 pati ents had significant benefits from early intervention using endovascular therapy with the Solitaire FR stent retriever as compared with alteplase alone. These patients had improved reperfusion, early neurological recovery, and functional outcome. The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial3 investigators showed that early endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation led to such good outcomes that the study had to be halted because of improved functional outcomes and reduced mortality in the cohort treated with alteplase plus endovascular therapy. These results show that the treatment protocols for acute stroke syndromes have been fundamentally altered.
Some questions remain in my mind after reading the 2015 American Heart Association/American Stroke Association guidelines. Because a majority of patients (60% to 80%) die within 90 days of alteplase treatment initiated for proximal vessel occlusion3 in the anterior circulation, must we not completely bypass the alteplase arm? What is the documented, pathophysiological benefit of alteplase in proximal vessel occlusion if ≤80% die within 90 days of a stroke and if the National Institutes of Health stroke scale is >6, for example? Are we wasting the drug in such clinical scenarios? Do we know if alteplase plus endovascular therapy are better as compared with endovascular therapy alone? Is it time to randomize all patients to endovascular therapy using the National Institutes of Health stroke scale as a guideline with a score of >6 slated for endovascular therapy, and do we not necessarily route them via alteplase treatment first? Have we chosen to persist with alteplase in all acute strokes because that is what we had in the mid-90s and it is the de facto stroke guideline for therapy?
Second, with time is brain being a central theme in stroke care management, why is there not a push to give alteplase in the emergency rooms, nationwide and by consensus, when the computed tomography of brain is negative for a bleed or a large stroke, if blood pressure/glucose are not exclusionary, and if other obvious contraindications are excluded? Should not tissue-type plasminogen activator in the truck be the theme of stroke care moving forward? Why do we need a neurologist or a stroke specialist to step in when National Institutes of Health stroke scale scoring is being done routinely by hospitalists, nurse practitioners, stroke nurses, and other staff, including paramedical staff? In fact, we need more endovascular/interventional stroke specialists because alteplase guidelines need minimal specialist need for administration of the drug.
Jagannadha Avasarala, MD, PhD
The authors chose not to respond.
Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.
- © 2015 American Heart Association, Inc.
- Powers WJ,
- Derdeyn CP,
- Biller J,
- Coffey CS,
- Hoh BL,
- Jauch EC,
- et al