Latest Clinical Guidelines for Management of Stroke
Brian Hoh MD, MBA, FACS, FAHA, FAANS, discusses the latest clinical guidelines for management of stroke. He examines pre-hospital management of acute ischemic stroke and stroke systems of care, the management of acute ischemic stroke in the Emergency Department and the evaluation of acute ischemic stroke patients for mechanical thrombectomy.
Featuring:
Brian Hoh, MD, MBA, FACS, FAHA, FAANS, is an internationally known expert in the treatment of brain aneurysms, brain arteriovenous malformations, and ischemic and hemorrhagic stroke. In July 2018, he was named the chair of the Lillian S. Wells Department of Neurosurgery at the University of Florida College of Medicine. Dr. Hoh graduated from Stanford University with a Bachelor of Arts and Science degree in biology and political science. He attended medical school at Columbia University in New York, where he graduated with Alpha Omega Alpha honors. Dr. Hoh completed his internship in surgery, residency in neurological surgery and fellowship in interventional neuroradiology at Harvard University at Massachusetts General Hospital. He graduated with an MBA from the University of Florida Hough Graduate School of Business with Beta Gamma Sigma honors. Dr. Hoh is board-certified by the American Board of Neurological Surgery. He is president-elect of the Congress of Neurological Surgeons, past-chair of the Joint American Association of Neurological Surgeons/Congress of Neurosurgical Surgeons Cerebrovascular Section, a member of the Society of Neurological Surgeons, a senior member of the Society for Neurointerventional Surgery (formerly the ASITN), a member of the American Association of Neurological Surgeons and a member of the Florida Neurosurgical Society. In 2014, Dr. Hoh was elected to the prestigious American Academy of Neurological Surgery. Dr. Hoh is a past co-chair and member of the editorial board of the Journal of Neurosurgery and a past member of the editorial board of the Journal World Neurosurgery. Dr. Hoh is an NIH-R01-funded principal investigator of basic science research investigating the biologic mechanisms of cerebral aneurysm formation and rupture, as well as innovative tissue engineering technology to improve the treatment of cerebral aneurysms. He is also an investigator on national and international clinical trials focused on stroke, cerebral aneurysms, carotid stenting and endarterectomy, and vasospasm. Dr. Hoh is a leader in neurosurgical education. He is the past director of the UF residency program and the UF endovascular surgical neuroradiology fellowship program, both ACGME-accredited training programs. In these roles, he was responsible for the training of 21 neurosurgery residents and endovascular surgical neuroradiology fellows.
Brian Hoh, MD
Brian Hoh, MD is the Chair Lillian S. Wells Department of Neurosurgery James and Brigitte Marino Family Professor University of Florida College of MedicineBrian Hoh, MD, MBA, FACS, FAHA, FAANS, is an internationally known expert in the treatment of brain aneurysms, brain arteriovenous malformations, and ischemic and hemorrhagic stroke. In July 2018, he was named the chair of the Lillian S. Wells Department of Neurosurgery at the University of Florida College of Medicine. Dr. Hoh graduated from Stanford University with a Bachelor of Arts and Science degree in biology and political science. He attended medical school at Columbia University in New York, where he graduated with Alpha Omega Alpha honors. Dr. Hoh completed his internship in surgery, residency in neurological surgery and fellowship in interventional neuroradiology at Harvard University at Massachusetts General Hospital. He graduated with an MBA from the University of Florida Hough Graduate School of Business with Beta Gamma Sigma honors. Dr. Hoh is board-certified by the American Board of Neurological Surgery. He is president-elect of the Congress of Neurological Surgeons, past-chair of the Joint American Association of Neurological Surgeons/Congress of Neurosurgical Surgeons Cerebrovascular Section, a member of the Society of Neurological Surgeons, a senior member of the Society for Neurointerventional Surgery (formerly the ASITN), a member of the American Association of Neurological Surgeons and a member of the Florida Neurosurgical Society. In 2014, Dr. Hoh was elected to the prestigious American Academy of Neurological Surgery. Dr. Hoh is a past co-chair and member of the editorial board of the Journal of Neurosurgery and a past member of the editorial board of the Journal World Neurosurgery. Dr. Hoh is an NIH-R01-funded principal investigator of basic science research investigating the biologic mechanisms of cerebral aneurysm formation and rupture, as well as innovative tissue engineering technology to improve the treatment of cerebral aneurysms. He is also an investigator on national and international clinical trials focused on stroke, cerebral aneurysms, carotid stenting and endarterectomy, and vasospasm. Dr. Hoh is a leader in neurosurgical education. He is the past director of the UF residency program and the UF endovascular surgical neuroradiology fellowship program, both ACGME-accredited training programs. In these roles, he was responsible for the training of 21 neurosurgery residents and endovascular surgical neuroradiology fellows.
Transcription:
Melanie Cole, MS (Host): Today we’re discussing the latest clinical guidelines for the management of stroke. We will exam prehospital management of acute ischemic stroke and stroke systems of care, the management of acute ischemic stroke in the emergency department, and the evaluation of acute ischemic stroke patients for mechanical thrombectomy. My guest is Dr. Brian Hoh. He's the James and Brigitte Marino Family Professor and the chair in the department of neurosurgery at the University of Florida and UF Health Shands Hospital. Dr. Hoh, it’s a pleasure to have you join us today. Please start by telling us the prevalence of people effected by stroke in the United States.
Brian Hoh MD, MBA, FACS, FAHA, FAANS (Guest): Stroke occurs in about 900,000 people in the U.S. each year. It’s the fifth leading cause and the leading cause of disability in the U.S. On average, about every 40 seconds someone in the U.S. has a stroke. One of every 18 deaths in the U.S. is from a stroke.
Host: Wow. Well it certainly is prevalent. So Dr. Hoh, does the chain of events favoring good functional outcomes from an acute ischemic stroke, does that being with the recognition of stroke when it occurs? Does the data show that the public knowledge of stroke warning signs is adequate?
Dr. Hoh: The outcome after an acute stroke starts with well-timed recognition and then care for the patient happening as soon as possible. That starts in the prehospital setting when EMS arrives where the patient is in the field.
Host: Well then even before we get into the importance of a designated stroke center, let’s talk about stroke systems of car and the role of that prehospital provider situation. So please begin with the prehospital management and field treatment? What's important as far as EMS? Why is it so important that a patient or if someone suspects that they or a loved one are having a stroke that they call 911?
Dr. Hoh: It’s extremely important because when an EMS arrives to take care of a patient, they need to recognize that a stroke may be occurring. The reason why this is important is because time is brain. Every minute that treatment for acute stroke is delayed results in a worse outcome for the patient. Essential to that treatment is getting that patient to a center that can provide the appropriate stroke care.
Host: Dr. Hoh, please tell us about the importance of a designated stroke center and stroke care in the quality improvement process. How does a center achieve that designation and tell us about the designation at UF Health Shands Hospital.
Dr. Hoh: A stroke center designation is critically important. This is because EMS taking care of that acute stroke patient in the field will need to know where to take that patient for appropriate stroke care. IV alteplase is the first line treatment for acute stroke. So obviously a patient needs to go to a hospital that can provide IV alteplase, but if there's a hospital that’s equally close by or not that much further away that can offer endovascular mechanical thrombectomy then that would be the preferred destination for that patient because then a comprehensive treatment paradigm can be offered for that patient.
There are several certifications and designations for stroke hospitals, but the highest possible designation is a joint commission comprehensive stroke center. UF Health Shands Hospital is a joint commission comprehensive stroke center, which represents the top 2% of hospitals in the country taking care of stroke. In order to qualify as a joint commission comprehensive stroke center we had to demonstrate through rigorous metrics that provide an interdisciplinary treatment approach to stroke patients and qualify by rigorous metrics for door to needle times, door to endovascular times, and outstanding outcomes for our stroke patients.
Host: Well, I understand that you're one of the authors of the stroke guidelines. How were you chosen to be on the writing group for those guidelines?
Dr. Hoh: The American Heart Association and American Stroke Association publishes their clinical guidelines for the early management of patients with acute ischemic stroke. They gathered a number of writing authors who were considered experts in the field for acute stroke care.
Host: That is so interesting. As we learn about those guidelines, do you feel that the development of an organized protocol and stroke team, that that speeds that clinical assessment, the performance of diagnostic studies and decisions for early management? Please explain emergency evaluation and diagnosis of acute ischemic stroke and the latest clinical guidelines.
Dr. Hoh: Standardized treatment protocols for acute stroke are critical. At certified stroke centers, standardized protocols dictate eligibility for patients to receive IV alteplase, which is the first line treatment for acute stroke. Also, these guidelines can aid providers in choosing the best blood pressure management, blood glucose management, and other parameters for optimizing patients for the best possible outcome after an acute stroke. For large vessel occlusion, which is the severest type of acute stroke, patients might be eligible for mechanical thrombectomy and standardized protocols for getting these patients to endovascular treatment can be critical to their outcome.
Host: So Dr. Hoh before we get into mechanical thrombectomy and even tPA use, once in the emergency department what imaging should an acute ischemic stroke patient have? What tests should be performed? Please speak about some of the imaging and what’s new and exciting in the area.
Dr. Hoh: Once the diagnosis of acute ischemic stroke versus hemorrhagic stroke has been established by the non-contrast head CT scan, if the patient is eligible for IV alteplase, he or she should receive that. Then it will be essential to determine whether the patient has a large vessel occlusion. That can be determined by imaging called CT angiogram or MR angiogram, which shows the blood vessels of the brain and can aid in the diagnosis of a large vessel occlusion. This is important because large vessel occlusion can be treated by endovascular treatment called mechanical thrombectomy.
Host: Then tell us about the use of tPA and the implications for rapid response treatment. Tell us about the time window for its use and some concerns with using it and managing these patients.
Dr. Hoh: Patients with acute ischemic stroke who are eligible should definitely receive IV alteplase if they present within three hours of ischemic stroke symptom onset. That’s a level 1A recommendation in the AHA/ASA guidelines, but it’s also recommended that patients within three to four and a half hours of ischemic stroke also be candidates eligible for IV alteplase. That’s supported by a number of European clinical trials that showed it’s benefits in these patients. That’s a level 1B-R recommendation in the current AHA/ASA guidelines.
Host: Then what about the use of endovascular interventions such as mechanical thrombectomy? Tell us the latest clinical guidelines for indications for use?
Dr. Hoh: The current AHA/ASA guidelines recommends strongly with a level 1A recommendation that patients with a large vessel occlusion in the anterior circulation who have a prestrike modified Rankin score of zero to one, meaning they are not disabled at baseline, who are age 18 or older who have a severe stroke—meaning an NIH stroke score of six or greater—and have CT imaging demonstrating an ASPECTS score of six or greater should receive mechanical thrombectomy within six hours of symptom onset. However, if patients present between the time windows of six to 16 hours or even 16 to 24 hours and they meet the eligibility criteria including profusion imaging on CT profusion or MR profusion that they receive mechanical thrombectomy as well.
Host: Well, thank you for that comprehensive answer. So after diagnosis, speak about general support of care and treatment of acute complications. For example, blood pressure and the role of aspirin or dual anti-platelet medications after stroke. Tell us about some of the things that go on after the stroke and the multidisciplinary care that a patient usually needs to receive?
Dr. Hoh: So the guidelines give recommendations that blood pressure be maintained at less than 180 systolic and 105 diastolic after an acute ischemic stroke and during and for the 24 hours after a mechanical thrombectomy procedure. It’s recommended that patients receive aspirin within 24 to 48 hours after the onset of an acute ischemic stroke. For those treated with IV alteplase, aspirin is generally delayed until 24 hours later. Aspirin is also recommended for patients that undergo mechanical thrombectomy.
Host: So interesting. The technology, right now, is really amazing. Dr. Hoh, tell us about some promising new therapies. If you were to look forward to the next 10 years in the field, what do you feel will be some of the more important areas of research for stroke care?
Dr. Hoh: Well, there are always continuing evolution and development in the endovascular devices and techniques we use for mechanical thrombectomy. Certainly the current generation of endovascular devices that we use are much better than the first devices that we used in the past and were developed, and we’re getting much better outcomes for our patients. So I see in the future continued evolution and development of better and more innovative endovascular devices and techniques. Also there are currently no pharmacologic or non-pharmacologic neuroprotective treatments to treat patients with acute stroke, but there’s always the hope that in the future that a neuroprotective agent will be found that will also aid our acute ischemic stroke patients.
Host: Wow, what an exciting time. Dr. Hoh, as we wrap up what else would you like other providers to know about UF Health Shands Hospital at the University of Florida stroke program and when they should consider a transfer or referral to this program.
Dr. Hoh: UF Health Shands Hospital is a joint commission comprehensive stroke center, which means that it is one of the top two percent of hospitals in the country taking care of stroke. As a comprehensive stroke center, we obviously offer IV alteplase and other stroke treatments, but also have 24/7 365 endovascularly mechanical thrombectomy providers that can provide this essential treatment for patients with large vessel occlusion as well as other types of ischemic and hemorrhagic stroke.
Host: Please end by telling us about your team.
Dr. Hoh: We are fortunate to have an interdisciplinary team of emergency medicine physicians, EMS, vascular neurosurgeons, vascular neurologists, neurocritical care physicians, nursing, physical therapy, occupational therapy, speech and swallow, case management, as well as a multitude of other services that are skilled and certified to take care of stroke patients.
Host: Wow. That certainly is multi-disciplinary and such a comprehensive stroke program. Thank you so much, Dr. Hoh, for joining us and sharing your incredible expertise today. That wraps up this episode of UF Health Med Ed Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on Facebook and Twitter. I'm Melanie Cole.
Melanie Cole, MS (Host): Today we’re discussing the latest clinical guidelines for the management of stroke. We will exam prehospital management of acute ischemic stroke and stroke systems of care, the management of acute ischemic stroke in the emergency department, and the evaluation of acute ischemic stroke patients for mechanical thrombectomy. My guest is Dr. Brian Hoh. He's the James and Brigitte Marino Family Professor and the chair in the department of neurosurgery at the University of Florida and UF Health Shands Hospital. Dr. Hoh, it’s a pleasure to have you join us today. Please start by telling us the prevalence of people effected by stroke in the United States.
Brian Hoh MD, MBA, FACS, FAHA, FAANS (Guest): Stroke occurs in about 900,000 people in the U.S. each year. It’s the fifth leading cause and the leading cause of disability in the U.S. On average, about every 40 seconds someone in the U.S. has a stroke. One of every 18 deaths in the U.S. is from a stroke.
Host: Wow. Well it certainly is prevalent. So Dr. Hoh, does the chain of events favoring good functional outcomes from an acute ischemic stroke, does that being with the recognition of stroke when it occurs? Does the data show that the public knowledge of stroke warning signs is adequate?
Dr. Hoh: The outcome after an acute stroke starts with well-timed recognition and then care for the patient happening as soon as possible. That starts in the prehospital setting when EMS arrives where the patient is in the field.
Host: Well then even before we get into the importance of a designated stroke center, let’s talk about stroke systems of car and the role of that prehospital provider situation. So please begin with the prehospital management and field treatment? What's important as far as EMS? Why is it so important that a patient or if someone suspects that they or a loved one are having a stroke that they call 911?
Dr. Hoh: It’s extremely important because when an EMS arrives to take care of a patient, they need to recognize that a stroke may be occurring. The reason why this is important is because time is brain. Every minute that treatment for acute stroke is delayed results in a worse outcome for the patient. Essential to that treatment is getting that patient to a center that can provide the appropriate stroke care.
Host: Dr. Hoh, please tell us about the importance of a designated stroke center and stroke care in the quality improvement process. How does a center achieve that designation and tell us about the designation at UF Health Shands Hospital.
Dr. Hoh: A stroke center designation is critically important. This is because EMS taking care of that acute stroke patient in the field will need to know where to take that patient for appropriate stroke care. IV alteplase is the first line treatment for acute stroke. So obviously a patient needs to go to a hospital that can provide IV alteplase, but if there's a hospital that’s equally close by or not that much further away that can offer endovascular mechanical thrombectomy then that would be the preferred destination for that patient because then a comprehensive treatment paradigm can be offered for that patient.
There are several certifications and designations for stroke hospitals, but the highest possible designation is a joint commission comprehensive stroke center. UF Health Shands Hospital is a joint commission comprehensive stroke center, which represents the top 2% of hospitals in the country taking care of stroke. In order to qualify as a joint commission comprehensive stroke center we had to demonstrate through rigorous metrics that provide an interdisciplinary treatment approach to stroke patients and qualify by rigorous metrics for door to needle times, door to endovascular times, and outstanding outcomes for our stroke patients.
Host: Well, I understand that you're one of the authors of the stroke guidelines. How were you chosen to be on the writing group for those guidelines?
Dr. Hoh: The American Heart Association and American Stroke Association publishes their clinical guidelines for the early management of patients with acute ischemic stroke. They gathered a number of writing authors who were considered experts in the field for acute stroke care.
Host: That is so interesting. As we learn about those guidelines, do you feel that the development of an organized protocol and stroke team, that that speeds that clinical assessment, the performance of diagnostic studies and decisions for early management? Please explain emergency evaluation and diagnosis of acute ischemic stroke and the latest clinical guidelines.
Dr. Hoh: Standardized treatment protocols for acute stroke are critical. At certified stroke centers, standardized protocols dictate eligibility for patients to receive IV alteplase, which is the first line treatment for acute stroke. Also, these guidelines can aid providers in choosing the best blood pressure management, blood glucose management, and other parameters for optimizing patients for the best possible outcome after an acute stroke. For large vessel occlusion, which is the severest type of acute stroke, patients might be eligible for mechanical thrombectomy and standardized protocols for getting these patients to endovascular treatment can be critical to their outcome.
Host: So Dr. Hoh before we get into mechanical thrombectomy and even tPA use, once in the emergency department what imaging should an acute ischemic stroke patient have? What tests should be performed? Please speak about some of the imaging and what’s new and exciting in the area.
Dr. Hoh: Once the diagnosis of acute ischemic stroke versus hemorrhagic stroke has been established by the non-contrast head CT scan, if the patient is eligible for IV alteplase, he or she should receive that. Then it will be essential to determine whether the patient has a large vessel occlusion. That can be determined by imaging called CT angiogram or MR angiogram, which shows the blood vessels of the brain and can aid in the diagnosis of a large vessel occlusion. This is important because large vessel occlusion can be treated by endovascular treatment called mechanical thrombectomy.
Host: Then tell us about the use of tPA and the implications for rapid response treatment. Tell us about the time window for its use and some concerns with using it and managing these patients.
Dr. Hoh: Patients with acute ischemic stroke who are eligible should definitely receive IV alteplase if they present within three hours of ischemic stroke symptom onset. That’s a level 1A recommendation in the AHA/ASA guidelines, but it’s also recommended that patients within three to four and a half hours of ischemic stroke also be candidates eligible for IV alteplase. That’s supported by a number of European clinical trials that showed it’s benefits in these patients. That’s a level 1B-R recommendation in the current AHA/ASA guidelines.
Host: Then what about the use of endovascular interventions such as mechanical thrombectomy? Tell us the latest clinical guidelines for indications for use?
Dr. Hoh: The current AHA/ASA guidelines recommends strongly with a level 1A recommendation that patients with a large vessel occlusion in the anterior circulation who have a prestrike modified Rankin score of zero to one, meaning they are not disabled at baseline, who are age 18 or older who have a severe stroke—meaning an NIH stroke score of six or greater—and have CT imaging demonstrating an ASPECTS score of six or greater should receive mechanical thrombectomy within six hours of symptom onset. However, if patients present between the time windows of six to 16 hours or even 16 to 24 hours and they meet the eligibility criteria including profusion imaging on CT profusion or MR profusion that they receive mechanical thrombectomy as well.
Host: Well, thank you for that comprehensive answer. So after diagnosis, speak about general support of care and treatment of acute complications. For example, blood pressure and the role of aspirin or dual anti-platelet medications after stroke. Tell us about some of the things that go on after the stroke and the multidisciplinary care that a patient usually needs to receive?
Dr. Hoh: So the guidelines give recommendations that blood pressure be maintained at less than 180 systolic and 105 diastolic after an acute ischemic stroke and during and for the 24 hours after a mechanical thrombectomy procedure. It’s recommended that patients receive aspirin within 24 to 48 hours after the onset of an acute ischemic stroke. For those treated with IV alteplase, aspirin is generally delayed until 24 hours later. Aspirin is also recommended for patients that undergo mechanical thrombectomy.
Host: So interesting. The technology, right now, is really amazing. Dr. Hoh, tell us about some promising new therapies. If you were to look forward to the next 10 years in the field, what do you feel will be some of the more important areas of research for stroke care?
Dr. Hoh: Well, there are always continuing evolution and development in the endovascular devices and techniques we use for mechanical thrombectomy. Certainly the current generation of endovascular devices that we use are much better than the first devices that we used in the past and were developed, and we’re getting much better outcomes for our patients. So I see in the future continued evolution and development of better and more innovative endovascular devices and techniques. Also there are currently no pharmacologic or non-pharmacologic neuroprotective treatments to treat patients with acute stroke, but there’s always the hope that in the future that a neuroprotective agent will be found that will also aid our acute ischemic stroke patients.
Host: Wow, what an exciting time. Dr. Hoh, as we wrap up what else would you like other providers to know about UF Health Shands Hospital at the University of Florida stroke program and when they should consider a transfer or referral to this program.
Dr. Hoh: UF Health Shands Hospital is a joint commission comprehensive stroke center, which means that it is one of the top two percent of hospitals in the country taking care of stroke. As a comprehensive stroke center, we obviously offer IV alteplase and other stroke treatments, but also have 24/7 365 endovascularly mechanical thrombectomy providers that can provide this essential treatment for patients with large vessel occlusion as well as other types of ischemic and hemorrhagic stroke.
Host: Please end by telling us about your team.
Dr. Hoh: We are fortunate to have an interdisciplinary team of emergency medicine physicians, EMS, vascular neurosurgeons, vascular neurologists, neurocritical care physicians, nursing, physical therapy, occupational therapy, speech and swallow, case management, as well as a multitude of other services that are skilled and certified to take care of stroke patients.
Host: Wow. That certainly is multi-disciplinary and such a comprehensive stroke program. Thank you so much, Dr. Hoh, for joining us and sharing your incredible expertise today. That wraps up this episode of UF Health Med Ed Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on Facebook and Twitter. I'm Melanie Cole.