It is an exciting time to be taking care of stroke patients. It was only 22 years ago when the first acute ischemic stroke treatment (intravenous [IV] alteplase) became Food and Drug Administration–approved in the United States. This drug was proven safe, and improved functional outcomes in one out of three patients. But the time window was short as IV tissue plasminogen activator (tPA) was only approved for up to 3 hours after time of onset of symptoms.
Since then, we have progressed by leaps and bounds in acute interventions. The latest news with the positive results from Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) and Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 3 (DEFUSE-3) trials suggests that our acute interventions are beneficial for an even larger population of patients up to 24 hours after acute ischemic stroke. Advancements in perfusion imaging have made appropriate patient selection easier and expanded the number of eligible patients. Hospitals are striving to expand their time windows and improve their systems of care in order to meet the demands of a larger population of acute stroke patients. At my hospital, we have already developed policies and protocols to allow front-line staff to notify stroke neurology on call for patients who present with severe neurologic symptoms if they are within 6 hours (or upon awakening) from their last seen normal time.
Furthermore, recent updates in patent foramen ovale (PFO) trials suggest that PFO closure is indeed a good option for an appropriate subset of young cryptogenic stroke patients. This, in addition to the Watchman device (Boston Scientific Corporation) for secondary stroke prevention in atrial fibrillation, has expanded our options for embolic stroke prevention and provided options for patients who are not good anticoagulation candidates. These treatments require neurologists to work closely with cardiology colleagues. Neurologists should be the first line of referral and determine the appropriate candidates for these secondary prevention treatments. Identifying a streamlined referral pathway to interventional cardiology would benefit neurology practice operations and improve patient satisfaction.
As more interventions and treatments are available, stroke expertise is highly valued. To provide the broadest reach of neurologic expertise to our communities, systems have been developed to enhance this reach via telemedicine and mobile stroke units. What will further move this expansion will be changes in payment models and payor reimbursement.
This stroke edition of Practical Neurology is full of highlights of recent trials and reviews discussing the management of acute stroke patients, secondary prevention, and policy updates. Next steps and further progress in acute ischemic stroke should focus not only on providing the best care for patients who present to our hospital doorsteps, but casting a broad net to care for our patients in our geographic regions and thinking about our international colleagues who also benefit from outreach, further education, and development to provide better care for stroke patients worldwide.
Waimei Amy Tai, MD
Christiana Care Health System