Delayed care remains a problem
Yet, even if centers can ensure quality care, problems getting there may stand in the way. A study presented at ASA’s 2019 International Stroke Conference suggests that 64% of areas in the US lie outside a maximum 30 minutes’ drive and are classified as very high/high need for a TSC center.8
While the number of TSC centers is growing, for now they are concentrated on the East and West coasts. A broad swath of the middle of the country lies more than 60 minutes’ drive or helicopter flight from one of these facilities.4
Mobile stroke units (MSUs), with on-board imaging, laboratory and telemedicine capabilities to support diagnosis and treatment, may improve stroke triage decisions, especially in rural areas. But providers debate whether MSUs improve outcomes and are worth the high price tag (about $1 million each).9
Momentum is also building to transport stroke patients directly to higher level stroke centers, when possible, rather than to the closest facility followed by transfer.
Yet the longest delay often happens even before calling 911. Up to 75% of patients arrive outside of the window of opportunity when they can receive treatment. One study showed that just 3.8% of patients with ischemic stroke received tissue plasminogen activator between 2005 and 2011, although that number has been growing.10
Every effort should be made to expand access to these beneficial treatments for eligible stroke patients, without losing sight of the big picture. Continued efforts are needed to improve education about stroke in the community, in order to widen the pool of eligible patients who are likely to benefit from advances in stroke care.
1. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110. doi: 10.1161/STR.0000000000000158.
2. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708-718. doi: 10.1056/NEJMoa1713973.
3. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11-21. doi: 10.1056/NEJMoa1706442.
4. AHA. 50th anniversary stroke coordinator bootcamp. March 27, 2018. Accessed April 24, 2019 at: https://www.heart.org/idc/groups/heart-public/@wcm/@gra/documents/downloadable/ucm_499924.pdf
5. Mack WJ, Mocco J, Hirsch JA, et al. Thrombectomy stroke centers: the current threat to regionalizing stroke care. J Neurointerv Surg. 2018;10:99-101. doi: 10.1136/neurintsurg-2017-013721.
6. Society of Neurointerventional Surgery. Public Statement from the Society of NeuroInterventional Surgery, Joint Cerebrovascular Section of the AANS and CNS, and Society of Vascular and Interventional Neurology. Accessed April 24, 2019.
7. Fargen KM, Fiorella DJ, Mocco J. Practice makes perfect: establishing reasonable minimum thrombectomy volume requirements for stroke centers. J NeuroIntervent Surg. 2017;9: 717-719. doi: 10.1136/neurintsurg-2017-013209.
8. AHA. Study shows need for thrombectomy-capable stroke centers remains high in 64 percent of communities studied. Accessed April 24, 2019 at: https://newsroom.heart.org/news/study-shows-need-for-thrombectomy-capable-stroke-centers-remains-high-in-64-percent-of-communities-studied
9. Bukata R. Are mobile CT stroke units worth the price tag? Emergency Physicians Monthly. 2017;1:15-18.
10. AHA. Many stroke patients do not receive life-saving therapy. American Stroke Association Meeting Report – Session A17 – Abstract 116. February 23, 2017. Accessed April 24, 2019 at: http://newsroom.heart.org/news/many-stroke-patients-do-not-receive-life-saving-therapy