The mantra of ‘time is brain’ still applies in stroke management

Prof Peter Kelly, Stroke Service Director at Mater Misericordiae University Hospital, Dublin, delivered a practically grounded and comprehensive overview of ‘Updates on stroke emergency management’ at the Irish Neurological Association and the Association of British Neurologists Joint Meeting 2023. The presentation began with a synopsis of initial stroke management, and included a heavy emphasis on the one-hour door-to-treatment window, a fast, quality assessment, and the selection of appropriate patients for reperfusion therapy. “We don’t want to miss a single one,” he said.

Moving on to radiological imaging, Prof Kelly examined the advantages and disadvantages of CT and MRI in stroke diagnosis and management. “The big problem with CT is sensitivity for stroke,” he remarked, before acknowledging the higher sensitivity of MRI imaging. Addressing the risks of prolonged scanning time and other challenges with MRI, he concluded, “CT is really the workhorse that we use.” He then described the advances in multimodal CT and CT angiography, also adding that “the information gained is really valuable to select patients for late therapy”.

Attendees then received an overview of the current evidence guiding intravenous (IV) thrombolysis and thrombectomy. “The mantra of ‘time is brain’ still applies,” Prof Kelly said, as he described how the likelihood of excellent outcomes declines with time, age, and stroke severity. He talked about the leading fibrinolytics, alteplase and tenecteplase, and updated the room on the most recent evidence underpinning the current European Stroke Organisation (ESO) guidelines for thrombolysis. “If we have patients with acute ischaemic stroke, regardless of whether or not they are being considered for thrombectomy, they are within 4.5 hours, and there are no contraindications, treating with IV alteplase and tenecteplase at the 0.25mg/kg dose is a reasonable alternative to consider.”

Continuing with an update on best practice guidance in thrombectomy, Prof Kelly described the first successful thrombectomy trial based on vascular imaging that was published in 2015, the four trials that rapidly followed in 2016, and how they were pooled into the HERMES analysis. “The takeaway message from the HERMES analysis is, regardless of what metric was analysed, patients treated with thrombectomy did remarkably well compared to best medical management. The risk ratio for excellent outcomes was effectively doubled in the thrombectomy group…. The safety profile was acceptable with a statistical trend towards reduced death at 90 days in the thrombectomy group. I think it’s safe to say this was the biggest single jump forward in stroke therapeutics we had ever seen, and it was a pleasure to be there when these trials were presented.”

Summarising ESO guidelines again, Prof Kelly told his colleagues that if they had a patient with acute ischaemic stroke, with a large vessel occlusion of the anterior circulation within six hours, they are candidates for thrombectomy. “The challenge is identifying them and getting them to treatment fast.”