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What imaging leaders should know about changing stroke guidelines

August 28, 2018

    This past January, the American Heart Association and American Stroke Association expanded the window for which clot removal was an option for ischemic stroke patients based on the results of two major clinical trials: DAWN and DEFUSE 3.

    Should your stroke center become TSC-certified? Here's how to decide.

    Traditionally, mechanical thrombectomy for clot removal was only considered a viable option within six hours, but researchers found benefit from clot removal in certain cases up to 24 hours after onset. Considering that 85% of stroke cases, around 750,000 per year, are ischemic, the new guidelines should have a significant impact on stroke outcomes by increasing the number of patients who are eligible for treatment.

    In light of these new guidelines, here are three key takeaways for imaging leaders:

    1. Increased volumes expected

    With these new guidelines in place, imaging leaders should be prepared for increased imaging volumes for stroke patients. MRI or CT perfusion imaging is required to identify ischemic stroke patients who fit the necessary criteria for this extended treatment window, meaning that imaging programs can anticipate increased CT perfusion imaging use. Ideally, this imaging should occur at the facility initially receiving the patient to determine his or her eligibility for treatment and/or transport to a facility capable of thrombectomies. About half of the patients screened for eligibility in the DEFUSE 3 trial met the necessary criteria.

    2. Operational considerations

    Hospital and imaging leaders should evaluate their current imaging capabilities in light of these new guidelines. For programs that don't currently offer CT perfusion imaging, the decision may come down to weighing the costs of adding perfusion technology and enhanced tPA capabilities or re-evaluating transportation protocols to ensure patients get to a facility that does have CT perfusion capabilities. 

    Programs that already offer CT perfusion imaging may need to make operational changes in light of these changing guidelines. Increased volumes of perfusion imaging could strain machine capacity and ED technologist staffing. Furthermore, these programs need to ensure that they have adequate capabilities to provide post-processing and real time reads of these images. This may require increased staff training, outsourcing the post-processing step, or purchasing a commercial software program such as RAPID, which significantly reduces post-processing time on CT perfusion images.

    3. New stroke certification

    Hospitals that offer thrombectomy should also expect increased volumes. One comprehensive stroke center we spoke with estimated a 15% increase in stroke volumes since the guideline change. In addition to planning for increased volumes, these organizations should consider becoming a Thrombectomy-Capable Stroke Center (TSC), which is a new advanced stroke certification offered by the Joint Commission. This new certification slots in between the Primary Stroke Center and Comprehensive Stroke Center levels and is meant to "identify hospitals that meet rigorous standards for performing endovascular thrombectomy," according to the Joint Commission.

    We are currently conducting research on imaging's role in the changing landscape of stroke care. If you are facing challenges with imaging for stroke patients, are considering adopting new protocols or making new investments based on the updated guidelines, or have developed solutions to these issues and are willing to discuss them with our research team, please email me at aderholM@advisory.com


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