UI Physician Leads Stroke Care Update
A neurologist at University of Iowa Hospitals and Clinics in Iowa City led an effort to update the guidelines for caring for patients affected by stroke that appear for the current edition of Stroke: the Journal of the American Heart Association.
Harold Adams, M.D., a professor in the Department of Neurology in the UI Roy J. and Lucille A. Carver College of Medicine, chaired the panel of stroke specialists that reviewed the stroke care guidelines.
The writing group led by Adams concluded that intravenous delivery of an approved clot-busting drug remains the most beneficial proven intervention for ischemic stroke.
The guidelines focus on the crucial first hours from the time an ischemic stroke occurs through emergency evaluation and treatment in a hospital. Ischemic strokes, the most common type of stroke, are caused by a clot that blocks blood flow in an artery to the brain.
"We are pushing for the fastest possible treatment because 'time is brain.' For every minute that goes by, the likelihood of a poorer outcome increases," Adams said.
The panel emphasized the importance of public education on the symptoms of stroke. These usually occur suddenly and include:
-- Weakness or heaviness of one side of the body or face
-- Numbness and loss of sensation of one side of the body or face
-- Slurred speech
-- Difficulty in finding words or understanding others
-- Loss of vision in one or both eyes
-- Severe sense of imbalance, difficulty walking
-- Unusually severe headache with no known cause
When such symptoms occur, the first step should be to immediately dial 911 to request emergency medical care.
The new guidelines suggest emergency medical personnel perform quick stroke assessment, draw blood and alert the hospital that a patient with a suspected stroke is coming. Patients should also be transported to the nearest "appropriate" hospital for emergency stroke care even if that means bypassing the closest facility or calling for air evacuation.
"Appropriate" facilities are those with the expertise and resources to provide modern emergency stroke care, such as UI Hospitals and Clinics, the state's only comprehensive health care center. UI Hospitals and Clinics has also earned the Gold Seal of Approval from the Joint Commission for Primary Stroke Centers. Regional plans for paramedics to bypass institutions that do not have emergency stroke care should be developed, according to the guidelines. The updated guidelines are an extensive revision of those issued in 2003 and 2005.
Intravenous delivery of the clot-busting drug tissue plasminogen activator (tPA) is only approved for use within three hours of the onset of symptoms.
Among the new or revised recommendations:
-- Hospitals should develop emergency stroke protocols so patients can be assessed and treated within 60 minutes of arrival in an emergency treatment center.
-- More medical centers should seek certification as primary or comprehensive stroke centers from the Joint Commission on Accreditation of Healthcare Organizations.
-- Patients should receive early and carefully chosen treatments for abnormal blood pressure, fever or abnormal blood sugar levels, which can negatively affect stroke outcome.
The panel said other techniques - mechanical devices and intra-arterial administration (IA) of tPA - are becoming more widely available and should be considered for patients with moderate-to-severe strokes who arrive at the hospital too late to receive intravenous tPA. However, information on these techniques is limited and more research is needed.
Although clot-dissolving drugs other than tPA are being tested, none has been established as effective and they should only be given as part of a clinical trial.
For the first time, the association has included comments about palliative or comfort care of a patient with a devastating brain injury.
"We included this in the document so that physicians may recognize that they can take measures to not prolong suffering or dying in a patient whose extensive brain injury will result in a fatal outcome," Adams said.
Co-authors include Gregory del Zoppo, M.D., the panel's vice chair; Mark J. Alberts, M.D.; Deepak L. Bhatt, M.D.; Anthony Furlan, M.D.; Robert L. Grubb, M.D.; Randy Higashida, M.D.; Edward C. Jauch, M.D.; Chelsea Kidwell, M.D.; Pat Lyden, M.D.; Lewis B. Morgenstern, M.D.; Adnan I. Qureshi, M.D.; Robert H. Rosenwasser, M.D.; Phillip A. Scott, M.D.; Eelco F.M. Wijdicks, M.D.; and Lawrence Brass, M.D. (deceased).
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