Keynote Address: Principles of Effective Management of Acute Stroke
K.M.A. Welch, M.D.
Henry Ford Hospital and Health Sciences Center, Detroit, Michigan
From Shakespearean times and beyond, stroke has aged our youth, destroyed the autumn of our life, and chilled the winter of our discontent. But in more recent times, there has been a major change in the effect stroke has had on our lives and we are hopeful that there will be future changes as well.
Over the last few years we have reached a number of milestones in the management of stroke. The list of milestones begins with the development of arteriography and echocardiography, procedures that were first used in the early 1950s. Another major advance was the identification of risk factors for stroke and the discovery that these risk factors could be manipulated to reduce the incidence and prevalence of stroke.
The introduction of randomized clinical trials by the National Institute of Neurological Disorders and Stroke was a particularly notable step forward. These trials included not only trials for drugs like platelet inhibitors and anticoagulants, but also surgical trials. This was an extraordinary achievement for stroke research and major credit goes to the clinical scientists, particularly the surgeons, who provided the skills to conduct and design these trials. When we look back over the last 15 years at the results and changes brought about by these studies--the NASCET (1), the SPAF trials (2-4), the ACAS (5), and now the NINDS t-PA Stroke Study (6)--we can see just how extraordinary these programs are. They reflect clear planning and a great deal of foresight, and have had a major impact on the health of our society.
We entered another major technological era with the introduction of CT scanning and MRI/MRA, tools that will help us further define the progression of stroke in our patients.
But now we come to a new milestone in stroke management: advances in acute stroke treatment. The spotlight has been on t-PA and indeed this drug did precipitate the need for new strategies in acute stroke management. But our focus during this symposium has been not only on this new drug treatment, but also on how we manage acute stroke and the strategies we can use in the future to manage it more effectively. In addition, we hope that a number of other new brain protective drugs will be available soon and for which we will be prepared because of the new systems we develop as a result of this symposium.
This monograph outlines a number of underlying general principles of effective stroke management. The first is that the interests and needs of patients with stroke and their families should be the primary concern of all stroke care professionals. Progress in acute stroke management will only be achieved if stroke is considered a medical emergency and that means that all stroke patients must receive immediate evaluation at hospitals. Support by self-help and voluntary patient associations must be encouraged to educate the public about the symptoms of stroke so that care providers have the opportunity to deliver this immediate evaluation.
A second principle is that all current and future therapies for stroke should be based on scientific evidence, and treatments of unproved value should not be used routinely in stroke patients. Management of all aspects of disability should be planned in close collaboration with patients and their families. And collaboration in stroke research--including prevention, acute management, nursing care and rehabilitation, and education--should be promoted at local, national, and international levels taking into account the needs and contributions of all professional groups and patient associations.
These principles reflect the same essential principles for good practice that have been outlined by the Europeans in theHelsingborg Declaration of stroke management (7). The European community recently recognized the need for community strategies in the management of acute stroke and put this recognition on record. And now this monograph presents the generalized recommendations for changes in stroke management in the United States. The specific details of how this is carried out should be determined by organizations at the local level, and we recognize that regional implementation will vary widely.
Conclusions from this conference that all participants can agree on are summarized as follows:
Prehospital care : This part of our community is already willing to change and be flexible. In fact, the system needs only minor modifications to achieve the goals we have established of more rapid response to acute stroke. Perhaps more important is to establish that research is needed to continue to make improvements in our prehospital care of patients.
Emergency department care : For stroke, just as for myocardial infarction and trauma, it is essential that emergency departments be reorganized and realigned to work in concert with prehospital care providers and then to move carefully selected patients into acute hospital care departments.
Acute hospital care : This critical link in the management of stroke may be the most challenging in terms of making changes to accommodate the movement toward rapid treatment. But changes can and will occur, as was demonstrated in the NINDS t-PA Stroke Study. That study showed that, with proper management of the systems, we can indeed recruit patients within the 3-hour time-frame. We must work, however, to extend that therapeutic window, perhaps through the use of newer, sophisticated imaging techniques or with enhancement of CT scan diagnostic potential. Questions we should answer include: "Is reperfusion safe?" "Will treatment cause hemorrhage?" "What are the issues we should consider in predicting hemorrhagic conversion, staging of stroke, identifying viable tissue, predicting cell death, and identifying creative ways to extend the therapeutic window?"
Health care systems : We must work to continually improve integrated stroke management delivery systems. It is vital for us to create a system of care that responds appropriately to the needs of our patients while considering also the larger societal need to control costs.
Public education: The final domain is public education, that which is most essential if we are to deliver acute treatment strategies to patients. This is clearly the most difficult challenge--changing the behavior of our patients--and we will need to develop innovative processes to accomplish this goal.
A final observation is that we should set targets for ourselves: these targets should include establishing systems of organized management of acute stroke, providing access to specialized assessment and treatment at stroke centers, providing access to specialty stroke rehabilitation, and providing access to information on stroke prevention. We can never forget the importance of continuous improvements of our systems and quality assessment programs.
What rigorous targets can we set for ourselves? Suggestions include reducing the 1-month death rate to below 20%, reducing the 2-year recurrent fatal and nonfatal stroke rate to below 20%, reducing vascular death overall to less than 40%, and having 70% of our stroke patients engaged in activities of daily living at 3 months after stroke (7).
All of us involved in this effort should move forward with optimism to achieve these targeted goals and make successful management of acute stroke a reality for all communities.
1. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Investigators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325(7):445-453.
2. Stroke Prevention in Atrial Fibrillation (SPAF I) Investigators. The Stroke Prevention in Atrial Fibrillation study: Final results. Circulation 1991;84:527-539.
3. Stroke Prevention in Atrial Fibrillation (SPAF II) Investigators. Aspirin versus warfarin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II study. Lancet 1994;343:687-691.
4. Stroke Prevention in Atrial Fibrillation (SPAF III) Investigators. Adjusted dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996;348:633-638.
5. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273(18):1421-1428.
6. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587.
7. Adams HP Jr. Editorial: Stroke management in Europe. J Intern Med 1996;240:169-171.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last Modified May 17, 2011