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The American Heart Association/American Stroke Association (AHA/ASA) guidelines strongly recommend the development of primary stroke centers1

Guidelines for the early management of adults with ischemic stroke.


Stroke centers optimize care and may improve outcomes

Given the narrow therapeutic window for treatment of acute ischemic stroke, timely evaluation and diagnosis are critical.

American Heart Association/American Stroke Association (AHA/ASA) guidelines strongly recommend the development of primary stroke centers(1)

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"Golden hour" of stroke treatment

The National Institutes of Health (NIH) guidelines recommend that assessment of a suspected acute ischemic stroke patient be performed rapidly and a decision regarding treatment be made within 60 minutes of arrival in the ED3

NIH-recommended emergency department response times3

The "golden hour" for evaluation and treating acute stroke

Door To Treatment

  • *Activase must be administered within 3 hours of symptom onset. Please see the Prescribing Information for full eligibility requirements.

Rapid evaluation and assessment of the patient will facilitate timely administration of the appropriate stroke treatment4

Practices that may help create more efficient care of the patient include the following4:

  • Establishment of stroke teams
  • Prenotification of the ED and/or the stroke team directly, whenever possible, while the patient is in transit
  • Establishment of protocols for patients with AIS
  • Ongoing training programs for ED and EMS personnel and the stroke team
  • Interpretation of CT scan within 20 minutes in-house or by telestroke
  • CT scans available at all times

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Efficient stroke treatment. Improved stroke care1

The AHA/ASA guidelines stress that stroke centers are part of a stroke system of care — a much larger network that encompasses stroke prevention, education of healthcare practitioners and the public, acute care, rehabilitation, and quality improvement in the delivery of healthcare.

Impact of stroke units on outcomes at 1 year(5)

Adapted from Stroke Unit Trialists' Collaboration. Stroke. 1997;28:2139.

  • †
  • Median.
  • ‡
  • Based on the Wilcoxon rank sum test.
  • §
  • P <0.05.

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The Brain Attack Coalition (BAC) recommends 2 types of stroke centers4,6

Primary stroke center (PSC)

  • Appropriate for stabilizing and treating most cases of acute ischemic stroke
  • Can receive Joint Commission (JC) certification
  • Provides quality care for most patients

Comprehensive stroke center (CSC)

  • For more complex cases requiring advanced technology and specialized diagnosis and treatment
  • May receive patients from a PSC following stabilization and/or treatment
  • Functions as advisory or educational resource for other facilities in region

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BAC: primary stroke center criteria4

  • Acute stroke teams that are available 24/7
  • Written care protocols that include appropriate use of Activase (Alteplase)
  • Emergency medical services coordinating with ED
  • ED personnel trained in diagnosis and treatment of all strokes
  • Stroke unit (not necessarily a formal unit)||
  • Neurosurgical services available within 2 hours when needed
  • ||
  • A stroke unit is only required for those PSCs that provide ongoing in-hospital care for patients with stroke.

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BAC: comprehensive stroke center criteria4

Patient Care

  • Acute stroke teams
  • Written care protocols
  • Emergency medical services and department
  • Stroke unit (for hospitals providing inpatient care)
  • Neurosurgical services

Support services

  • Commitment and support of medical organization, including a designated stroke center director
  • Laboratory services
    • – Available 24/7
    • – Able to perform complete blood count, blood chemistry, and coagulation studies
  • Neuroimaging services
    • – Available 24/7
    • – Capable of performing noncontrast CT within 25 minutes
  • Outcome- and quality-improvement activities
  • At least 8 credit hours per year of continuing medical education for all members of the stroke team

Plus

  • Expanded personnel
  • Specialized diagnostic techniques
  • Advanced surgical and interventional capabilities
  • Infrastructure (stroke unit, ICU, 24/7 services)
  • Educational/research programs: community, professional, patient

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Benefit to patients, clinicians, and institutions1

Potential patient benefits

  • Rapid evaluation, diagnosis, and treatment from a multidisciplinary team
  • Improved chance of receiving appropriate care and subsequent good treatment outcomes

Support for cinicians

  • Standardized protocols
  • Comfort administering t-PA to eligible acute ischemic stroke patients
  • Regional expert centers
  • Patients available for clinical trials

Enhancement of hospital status

  • Stroke center certification provides independent, unbiased validation of internal practices
  • Recognition
  • Increased community awareness

Policy papers

Read stroke policy statements and guidelines from the American Academy of Neurology (AAN), the American College of Emergency Physicians (ACEP), the American Heart Association/American Stroke Association (AHA/ASA), and the Brain Attack Coalition (BAC).

The Brain Attack Coalition (BAC)

  • The BAC, in its 2005 consensus statement, Recommendations for Comprehensive Stroke Centers, recommends lytics as a component of a Comprehensive Stroke Center (CSC)# (grade IIB)**
  •   ¶
  • The Brain Attack Coalition (BAC) is a multidisciplinary group of professionals from major organizations involved with the care of patients with stroke and cerebrovascular disease.
  •   #
  • A comprehensive stroke center (CSC) is defined as a facility or system with the necessary personnel, infrastructure, expertise, and programs to diagnose and treat stroke patients who require a high intensity of medical and surgical care, specialized tests, or interventional therapies. Such patients include, but are not limited to, patients with ischemic stroke.
  • **
  • Supported by grade II evidence: data from randomized, controlled trial (RCT), but may have false positives or negatives; may not be FDA-approved, but therapy (Rx) is widely or commonly used in many medical centers.

Journal Article

Revised and Updated Recommendations for the Establishment of Primary Stroke Centers: A Summary Statement From the Brain Attack Coalition

Learn how your facility can become a stroke center or prepare for recertification by visiting JCAHO.

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Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Important Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.
2.
Chiu A, Shen Q, Cheuk G, Cordato D, Chan DKY. Establishment of a stroke unit in a district hospital: review of experience. Intern Med J. 2007;37:73-78.
3.
Jauch EC. The "golden hour" of acute ischemic stroke: treatment guidelines & recommendations. The Internet Stroke Center Web site. http://www.strokecenter.org/education/jauch/02.htm. Updated February 26, 2008. Accessed March 25, 2009.
4.
Alberts MJ, Hademenos G, Latchaw RE, et al; for the Brain Attack Coalition. Recommendations for the establishment of primary stroke centers. JAMA. 2000;283(23):3102-3109.
5.
Stroke Units Trialists' Collaboration. How do stroke units improve patient outcomes? Stroke. 1997;2:2139-2144.
6.
Alberts MJ, Latchaw RE, Selman WR, et al; for the Brain Attack Coalition. Recommendations for the establishment of comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36:1597-1618.
7.
Dion JE. Management of ischemic stroke in the next decade: stroke centers of excellence. J Vasc Interv Radiol. 2004;15:S133.