In Stroke Treatment, 15 Minutes Matters

A new study adds more evidence that quick treatment can reduce death and disability after a stroke. The study shows that getting treated even 15 minutes faster makes a difference. Researchers looked at data on more than 58,000 people who had ischemic strokes. This is the type of stroke caused by a blood clot. The best treatment is a drug that dissolves the clot. Guidelines say the drug should be given within 4½ hours of the beginning of stroke symptoms. The study looked at how quickly people got treated with a clot-busting drug and how well they did afterward. For every 15 minutes saved between symptoms appearing and drgu treatment, the odds of dying in the hospital or having excess bleeding dropped 4%. Speedier treatment also improved how well people were doing by the time they left the hospital. For every 15 minutes saved before treatment was given, people were 4% more likely to walk out of the hospital on their own. They were 3% more likely to go home rather than to a nursing home or rehab center. The Journal of the American Medical Association published the study. HealthDay News wrote about it June 18.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

When a stroke strikes, brain cells die quickly. The faster you recognize a stroke and get to the hospital, the faster treatment can begin.

It's a medical emergency similar to a heart attack. That's why many call it a "brain attack."

Brain cells require a constant supply of blood, carrying oxygen and nutrients. A stroke suddenly interrupts that supply. More than 80% of all cases are caused by a blood clot blocking an artery supplying the brain. Doctors call this an ischemic stroke.

The clot may form in a blood vessel within the brain (thrombotic stroke). Or the clot may form elsewhere and travel to the brain (embolic stroke).

The best treatment for an ischemic stroke is a clot-busting drug called tissue plasminogen activator (tPA). The sooner a doctor can inject tPA, the better the outcome.

Minutes matter. That's the finding of this study, which looked at 58,353 patients treated with tPA for ischemic strokes.

The clot-busting drug must be given within 4.5 hours from the time when stroke symptoms start. If not, tPA is less effective, and the risk of bleeding outweighs any small risk of benefit.

All patients in this study received the drug within the necessary time frame. And those who received it fastest had the best results.

For EVERY 15 minutes cut off the time from symptoms to tPA injection, there was:

• A 4% greater chance of walking independently at discharge from the hospital
• A 3% greater chance of going directly home from the hospital
• A 4% decrease in the risk of dying in the hospital
• A 4% lower chance of bleeding into the affected brain tissue

Besides the speed of treatment, the outcome of a stroke depends on:

• The size of the blood vessel affected
• The part of the brain that is supplied by the blocked artery

A clot in a small vessel near the outside edge of the brain might cause no symptoms. A clot in a major artery can paralyze half of the body. Severe symptoms at the start of a stroke mean a reduced chance of excellent recovery.

The major risk of tPA is bleeding into the brain. An ischemic stroke makes the affected part of the brain more fragile and more likely to bleed. As time passes from the start of stroke symptoms, bleeding risk increases.

According to this study, patients with the most severe symptoms improved their outcomes the most with quick treatment. And the sooner treatment started, the better.

What Changes Can I Make Now?

If you suspect someone is having a stroke, think FAST:

• Face: Ask the person to smile. Is one side drooping?
• Arms: Ask the person to lift both arms. Does one drift back down?
• Speech: Ask the person to repeat a simple sentence. Is it slurred or incomplete?
• Time: If one or more stroke signs are present, act quickly. Call 911, and get the person to the nearest hospital with an emergency department. If possible, it should be a hospital with a stroke center.

Before injecting tPA, a doctor must be sure that the stroke is not caused by bleeding into the brain. This is called a hemorrhagic stroke. An MRI or CT scan must be done first. That's why it's so important for the 911 operator to know you suspect a stroke. The emergency department can then be ready to get the brain imaging performed quickly.

You can take steps to help prevent strokes:

• Know and control your blood pressure.
• Don't smoke.
• Lose weight if needed.
• Become more active.
• Know and control your blood sugar and cholesterol.
• If you drink alcohol, do so in moderation.
• Adopt a healthy diet, such as a Mediterranean-style diet.

What Can I Expect Looking to the Future?

We have already seen improved outcomes in people with acute stroke. But there has been less progress in prevention, so too many strokes still happen. Prevention must start in childhood.