From the International Symposium on Endovascular Therapy
MIAMI BEACH—The point of stroke triage is to choose patients who might benefit from a coordinated, multisystem treatment effort, namely, patients with a defined acute onset of stroke and symptoms compatible with the accepted criteria for therapy, said Buddy Connors, MD, medical director of interventional neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla, at the18th annual International Symposium on Endovascular Therapy.
FAST, which stands for Face, Arm, Speech, and Time, is the acronym used to help focus the immediate evaluation of a potential stroke patient, Dr Connors said. A lopsided face, weak arm, and garbled speech are the most common warning signs of stroke. The time needed to save the brain from damage during a stroke is the most crucial issue when considering therapy.
“You have to know when the stroke started. If it started 2 days ago it is probably too late to do anything acutely, but if it started 15 minutes ago it needs to be an emergency of the highest priority. The time window for treatment for stroke is much shorter than that for a heart attack. It is crucial that stroke patients go through the workup and evaluation process rapidly to give them the best chance of a good therapeutic outcome,” Dr Conners explained.
Treatment begins with triage in the field or the office, and an appropriate destination hospital. “When they get to the hospital, the emergency physician has to determine whether to order immediate computed tomography [CT] scans, to see if it is a bleed or an ischemic stroke. If it is an ischemic stroke, we can do further tests, such as a CT angiogram, to see if there is a visible clot that can potentially be treated with intraarterial-catheter delivered therapy. For larger clots identifiable on CT angiography, if you start with an intravenous lytic agent followed by a catheter-directed lytic agent, this combination therapy can give benefits that are better than just intravenous therapy alone,” Dr Connors told .
Certain clots may be treated with clot retrievers, which reach the brain after being inserted through a microcatheter into the groin. The retriever then tangles up with the clot, allowing it to be pulled out of the brain. However, the retriever sometimes misses a clot fragment. A combination of the retriever and a lytic agent has been shown to successfully clear away any remaining pieces of the clot.
If there is bleeding in the brain, medical therapy is generally used, possibly some of the newer drugs that can prevent the bleeding from spreading. If it is an aneurysm bleed, coil endovascular therapy is now accepted as the standard of care. There are, however, certain aneurysms that will always need to be clipped by a neurosurgeon.
Intravenous therapy for ischemic stroke has some fundamental limitations. Catheter-directed therapy gives physicians more tools, but “we need to improve our arsenal of weapons on all fronts,” Dr Connors says. “We need better drugs, better devices, and better stroke systems where we get to the patients sooner and target their therapy better. The most typical devastating ischemic strokes are in the middle cerebral artery, causing massive neurological deficit, and if we get to those patients soon enough we can have a good success rate in eliminating the clot, and the patients can have a good recovery.”
Describing the importance of emergent care for stroke patients, Dr Connors said, “Stroke is treatable, time is brain. The more time wasted, the more of the brain is lost. Florida is the first state to pass regulations to set up both primary and comprehensive stroke centers, to give patients the best treatment possible, and we are going to spread this now across the nation.”
Remember FAST for stroke triage: Face, Arm, Speech, Time.
Suspect stroke when a patient presents with a lopsided face, weak arm, and garbled speech.
A stroke is like a time bomb; the more time wasted before therapy is started, the more brain function is lost.
A CT scan is used to distinguish an ischemic stroke from a bleeding etiology.