After a stroke, every minute counts: New national guide for care

Every minute that passes can make a difference in how well their brain, arms, legs, speech or thinking ability recover.

Now, new national guidelines for stroke treatment -- co-authored by a member of the University of Michigan Comprehensive Stroke Program -- make it clear just how much minutes count. They also lay out a role for all types of hospitals in treating stroke emergencies, including community hospitals of the type involved in a recent U-M led study of stroke care.

The American Stroke Association guidelines are published in the American Heart Association journal Stroke. The authors include Phillip Scott, M.D., a U-M emergency physician and member of the U-M Comprehensive Stroke Program.

Here are some key numbers:

• 90 percent -- the proportion of stroke victims whose symptoms are caused by clots blocking blood vessels in the brain, making them potential candidates for clot-busting therapy if they get to the hospital in time.
• 9-1-1 -- the number that people should call immediately after they or someone near them begins to experience symptoms of stroke, so that the patient can get to a stroke center hospital as soon as possible.
• 4.5 hours -- the maximum number of hours that can pass between the start of stroke symptoms and the start of clot-dissolving treatment (called tPA). Many patients delay seeking care, losing precious minutes.
• 2 million -- The approximate number of brain cells (neurons) lost for each minute delay in restoring blood flow after a stroke. Earlier treatment is better.
• 60 -- the number of minutes between the moment a typical stroke victim reaches a hospital, and the moment they get treatment to break up a blood clot in their brain. This "door to needle time" includes the time it takes to use brain scanners to tell whether a clot or bleeding is causing the stroke.
• 4 -- the number of letters in the word "FAST," which is an easy way to remember the sudden signs of a stroke:
  • Face drooping: Does one side of the face droop or is it numb?
  • Arm weakness: Is one arm weak or numb?
  • Speech difficulty: Is speech slurred, are you unable to speak, or are you hard to understand?
  • Time to call 9-1-1: If you have any of these symptoms, even if the symptoms go away, call 9-1-1 and get to the hospital immediately.
• 24/7- the hours in a day when hospitals of all kinds should be ready to handle the arrival of a stroke victim, no matter what level of stroke care the hospital can provide.

Air medical transport and telemedicine support from large stroke-center hospitals such as U-M should be used to supplement the care any particular hospital can provide, the guidelines say.

The new guidelines recommend integrating regional networks of comprehensive stroke centers (which offer 24/7, highly specialized treatment for all types of stroke); primary stroke centers (which provide 24/7 specialized care mainly for ischemic stroke); and acute stroke-ready hospitals (which can evaluate and treat most strokes but lack highly specialized capabilities), and community hospitals.

Among other major revisions to the guidelines: If feasible, patients should be rapidly transferred to the closest available certified primary care stroke center or comprehensive stroke center, which might involve air medical transport.

"However, for patients brought to hospitals that don't offer specialized stroke expertise, telemedicine and simple telephone support can provide real-time access to that expertise," says Scott. "If such a hospital partners with a primary or comprehensive stroke center, early treatment decisions can be made to treat patients."

Scott has directed a 24-hospital research effort, called INSTINCT (funded by the National Institute of Neurological Diseases and Stroke) that evaluated the ability of community hospitals to deliver stroke treatment safely and effectively, with training and 24/7 support available from U-M.

Other key recommendations in the new guidelines include:

• Multidisciplinary quality improvement (QI) committees should be created within hospitals to review and monitor stroke care quality.
• Recently introduced stent retrievers could potentially remove large blood clots more completely and quickly than tPA. But the devices shouldn't be a substitute for intravenous tPA and should only be used in clinical studies to determine if they improve patient outcomes.

Co-authors of the guidelines are: Jeffrey L. Saver, M.D.; Harold P. Adams Jr., M.D.; Askiel Bruno, M.D., M.S.; J. J. (Buddy) Connors, M.D.; Bart M. Demaerschalk, M.D., M.Sc.; Pooja Khatri, M.D.; Paul W. McMullan Jr., M.D.; Adnan I. Qureshi, M.D.; Kenneth Rosenfield, M.D.; Phillip A. Scott, M.D.; Debbie Summers, R.N., M.S.N.; David Z. Wang, D.O.; Max Wintermark, M.D.; and Howard Yonas, M.D.