COMMENTARY

Turning a Corner in Stroke Care

Alexander A. Khalessi, MD

Disclosures

June 05, 2014

Optimism and Progress in Stroke Care

As a neurosurgeon trained in cranial and endovascular neurosurgery, I greatly anticipate the International Stroke Conference (ISC) as an opportunity to engage the research community in advancing the care of patients with ischemic and hemorrhagic stroke. Fortunately, the historic nihilism in stroke care is giving way to renewed optimism and focused progress in our treatment and understanding of cerebrovascular disease.

In conjunction with preceding meetings by the Joint Cerebrovascular Section of the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) and Society of Neurointerventional Surgeons (SNIS), the ISC brings together neurosurgeons, radiologists, neurologists, and scientists dedicated to all elements of stroke care. Coupled with improved acute stroke imaging, these academic exchanges offer a real opportunity to consider ischemic stroke as an anatomical diagnosis based on the level of vascular occlusion, as opposed to a clinical syndrome. Heterogeneity among stroke patients has frustrated many past population-based research efforts in stroke care; anatomical stratification in ischemic disease carries significant promise in improving risk adjustment.

Holding the 4.5-Hour Mark

Improved understanding of the natural history of ischemic stroke is particularly important as we undertake a variety of primary and secondary prevention strategies. In acute ischemic stroke, 2 large meta-analyses[1,2] affirmed the benefit of intravenous tissue plasminogen activator (IV tPA) within 4.5 hours of symptom onset and suggested benefit in patients older than 80 years.

Several studies explored the use of tandem neuroprotective agents in conjunction with IV tPA. Chamorro and colleagues[3] reported a Spanish study of 421 patients with acute stroke who received uric acid and IV tPA; 40% were free of disability at 90 days compared with 33% who received placebo. In contradistinction, the FAST-MAG trial[4] failed to demonstrate the clinical benefit of prehospital administration of IV magnesium by emergency medical services (EMS) personnel to acute stroke patients. Although no clinical benefit was realized in terms of 3-month functional status, the FAST-MAG trial established important precedents in the safety and feasibility of EMS prehospital administration of neuroprotective agents.

The process lessons of the FAST-MAG trial resonate strongly with a second important theme from ISC: Processes of care are central to clinical outcome. American Heart Association efforts to target stroke processes of care yielded substantial improvements in population-based stroke indicators. In the comprehensive stroke center era, it remains clear that efficient identification and treatment of patients with acute stroke results in improved clinical outcomes.

Considering Unconventional Populations

Beyond the tandem themes of neuroprotection and processes of care, ISC further brought an improved understanding of patient populations not typically associated with ischemic stroke. Population studies presented at ISC emphasized the increased stroke risk among women in the perimenopausal[5] and peripartum[6] periods.

Among perimenopausal women, moderate exercise mitigated against the increased stroke risk associated with reduced endogenous hormone production. Similarly, increasing rates of stroke among young people was described at ISC; structural vascular disease and rising rates of youth obesity and diabetes were felt to be responsible for this trend. Structural vascular disease was particularly important in stroke patients in the setting of trauma.[7] Overall, these studies collectively emphasized the importance of considering a stroke diagnosis in these unconventional patient populations.

The ISC ultimately reflected larger trends in medical progress. As we rely on population-based studies to refine patient selection and evaluate neuroprotective agents in the setting of stroke, we continue to see iterative improvements in processes of care to ensure continued patient access to proven therapies. Although underemphasized at this year's conference, technical improvements in revascularization and evacuation of spontaneous intracerebral hemorrhages remain important topics on the horizon.

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