The New England Journal of Medicine recently tapped Dr. William Powers, professor and former chair of the UNC Department of Neurology, to write an article, “Acute Ischemic Stroke,” for its “Clinical Practice” series. The article, published on July 16, 2020, provides an evidence-based summary of treatment of patients with acute ischemic stroke together with an algorithm for doing so. Understanding treatment options is important to ensure prompt administration of appropriate care or referral.
The Journal’s “Clinical Practice” feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.
Key clinical points in the article include:
- Treatment for patients with acute ischemic stroke is guided by the time from the onset of stroke, the severity of neurologic deficit, and findings on neuroimaging. By convention, the time of stroke onset is established as the time that the patient was last known to be well (i.e., in a normal or baseline state, as confirmed by medical history).
- Intravenous thrombolysis with alteplase (a recombinant tissue plasminogen activator) improves outcomes in selected patients with acute ischemic stroke when administered within 4.5 hours after onset. Later treatment may improve outcomes in selected patients, with the treatment window extended to 9 hours from onset.
- Intraarterial catheter-based mechanical thrombectomy of occluded large intracranial arteries improves outcomes in selected patients with acute ischemic stroke when performed up to 24 hours after onset.
- The benefit of alteplase and mechanical thrombectomy is time-dependent, so assessment and treatment should be instituted rapidly.
- In selected patients with mild acute ischemic stroke who do not qualify for intravenous thrombolysis or mechanical thrombectomy, dual antiplatelet therapy with clopidogrel and aspirin when administered within 24 hours after onset and continued for 21 days lowers the risk of recurrent stroke.
Dr. Powers led the writing group which developed the guidelines for stroke treatment that were released by the American Stroke Association in 2018 and updated in 2019.