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Stroke Systems of Care

Casey Frey, Laura Bishop, Stacey Q. Wolfe, and Kyle M. Fargen

This is an edited extract from the full chapter ‘Stroke Systems of Care’ from Acute Stoke Management in the First 24 Hours: A Practical Guide for Clinicians (OUP, 2018).

Stroke is the fifth leading cause of death in the United States and accounts for around 1 in every 20 deaths in the United States [1]. Every year approximately 795,000 people experience a stroke; the vast majority (87%) of which are ischemic in nature. For every minute of ischemia, approximately 2 million neurons are irreversibly lost[2]. Therefore, early identification of stroke symptoms, emergency medical services (EMS) activation and transport, rapid imaging and diagnosis, and early initiation of treatment are paramount.

In 1996, after the Food and Drug Administration approval, intravenous (IV) tissue plasminogen activator (alteplase, tPA) was established as the standard of care therapy for patients presenting with acute ischemic stroke within three hours from symptom onset[3][4][5]. This temporal limitation was later revised after analysis of multiple trials demonstrated benefit of alteplase up to 4.5 hours after onset of symptoms[6][7].

Recently, seven randomized controlled trials have demonstrated benefit to mechanical thrombectomy for anterior circulation large vessel occlusions[8][9][10][11][12][13][14]. These trials have been transformative and have led the American Heart Association (AHA) to update societal guidelines and provide a Class I Recommendation, Level of Evidence A, that thrombectomy be pursued in patients with large vessel occlusions who meet certain criteria, most notably presentation within 6 hours of symptom onset[15]. Accordingly, the last decade has seen a paradigm shift where stroke care has been clustered into highly experienced stroke centers that have the necessary infrastructure, procedural capabilities, and specialized physicians required to manage complex stroke conditions and sequelae. However, large vessel occlusions or severe strokes only account for a small minority of patients presenting with ischemic stroke (24 per 100,000 person-years) [16].

While patient selection and treatments continue to improve, a number of important challenges remain. For instance, reperfusion therapies remain substantially underutilized, as less than 10% of patients presenting with acute stroke actually receive IV alteplase[17][18]. These observations highlight important questions: How do we ensure that as many stroke patients as possible are obtaining the best possible outcomes? How do we ensure that individuals in rural communities without access to large stroke centers continue to receive state-of-the-art stroke care as rapidly as possible? Given the time sensitivity of stroke, is it better to have a greater number of less experienced (lower patient volume) hospitals or triage to a smaller number of hospitals with greater volume and expertise?

Unlike the regionalization of trauma care, the current stroke model is a pseudo-regionalized system that is fragmented and redundant. This is largely due to its development in an uncoordinated manner lacking systemic oversight and control. The current model may lead to patients getting inappropriate care due to lack of expertise in local hospitals or due to inappropriate and arbitrary triage. The establishment and implementation of stroke care requires that governing bodies develop true regionalized care models, proven triage assessment tools, effective means of transportation, and a hierarchal system of care to manage both the acute stroke as well as sequelae from the insult. Fortunately, regionalized care is rapidly evolving through expansion of telestroke, the development of advanced certification for hospitals, and with improved guidelines for stroke care.

Acute Stroke Management in the First 24 Hours: A Practical Guide for Clinicians edited by Maxim Mokin, Edward C. Jauch, Italo Linfante, Adnan Siddiqu, and Elad Levy

About the Authors

Casey Frey, Department of Neurological Surgery, Wake Forest University, Winston-Salem, NC
Laura Bishop, MD, Assistant Professor, Neurology, Department of Neurology, Wake Forest University, Winston-Salem, NC
Stacey Q. Wolfe, MD, Program Director and Associate Professor, Department of Neurological Surgery, Wake Forest University, Winston-Salem, NC
Kyle M. Fargen, MD, MPH, Assistant Professor, Neurosurgery, Department of Neurological Surgery, Wake Forest University, Winston-Salem, NC


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