06:01pm Saturday 19 August 2017

New Guidelines Issued for Early Management of Acute Ischemic Stroke Patients

The American Heart Association/American Stroke Association has issued updated guidelines for the emergency treatment of patients with acute ischemic stroke, recommending endovascular treatment using small mechanical devices known as stent retrievers that grab and allow removal of large clots from a blocked artery in the brain. The new guidelines follow the results of five randomized clinical trials of endovascular treatment in the last year.

Dileep R. Yavagal, M.D., associate professor of neurology and neurological surgery, was part of the elite panel issuing the updated guidelines that add mechanical thrombectomy to the treatment regimen.

“The overwhelming efficacy of endovascular therapy with these devices, demonstrated in an array of ischemic stroke patients around the world, led us to make this highest class of treatment recommendation,” said Yavagal, who is also Director of Interventional Neurology at UHealth – University of Miami Health System. “These guidelines usher in a revolutionary change in the treatment of stroke nearly 20 years after approval of the intravenous clot-busting medication tPA. For the first time, we have recommended with the highest level of scientific certainty that patients with disabling strokes should be treated as soon as possible at stroke centers with endovascular clot removal. This treatment will vastly improve their chances of not being disabled from the stroke.”

The standard treatment has long been tissue plasminogen activator (tPA), a clot-busting drug that must be given intravenously within 4.5 hours in order to be effective. However, tPA does not always dissolve blood clots in larger arteries. In this type of stroke, endovascular therapy, similar to that used for heart attacks, is better in restoring blood flow in the brain and thereby leads to significantly less disability. Stroke is the nation’s number five cause of death and the number one cause of serious disability.

The American Heart Association guidelines now recommend performing a mechanical thrombectomy within six hours of acute stroke symptoms. This is preferably done in conjunction with a patient receiving intravenous (IV) tPA but can also be beneficial if the patient is not a candidate for IV tPA. To remove a clot, doctors thread a catheter through the groin artery up to the blocked artery in the brain under specialized X-ray guidance. The stent opens up and grabs the clot, allowing the physician to remove the stent with the trapped clot.

Five studies, all published in the New England Journal of Medicine in the past six months, demonstrated that this new treatment benefits patients having a stroke due to blockage of a large artery in the brain. Yavagal led the University of Miami/Jackson Memorial Hospital site of one of those studies, called the SWIFTPRIME (Solitaire With the Intention For Thrombectomy as PRIMary Endovascular treatment) study, which examined the use of Solitaire, a stent-retrieval device made by Medtronic. He was also on the data safety monitoring board of another study, ESCAPE, in that group of studies.

“The SWIFTPRIME and other trials clearly showed that mechanical thrombectomy can reduce long-term disability in thousands of patients,” said Ralph L. Sacco, M.D., M.S., Professor and Chairman of Neurology, Olemberg Family Chair in Neurological Disorders and President-elect of the American Academy of Neurology.

“At UHealth, we have been pioneers in bringing this treatment to South Florida patients,” said Yavagal. “In issuing these guidelines, we’re able to expand this revolutionary approach to larger numbers of stroke patients and improve their outcomes.”

University of Miami


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