New Resident Guide to Stroke Alerts - Part 1

In part one of this series, Dr. Andy Southerland and Dr. Dan Ackerman discuss what stands out in the latest thrombolysis guidelines, how these decisions are applied in stroke center practice, and how to educate residents and fellows on incorporating new evidence into treatment choices.

Show transcript:

Dr. Andy Southerland:

Hi. This is Andy Southerland from the University of Virginia, and for today's Neurology Minute, I'm speaking with my friend and colleague, Dan Ackerman, Chief of Neurology and Director of Stroke at St. Luke's University Health System. I've been speaking with Dan on the main neurology podcast regarding updates to acute stroke treatment related to the 2026 American Heart Association guidelines that came out in late January of this year on the early management of patients with acute ischemic stroke.

For our episode today, we might focus our discussion around thrombolytic therapy thrombolysis, which is at the core of what we do as acute stroke neurologists when it comes to treatment decision-making. So maybe as a first prompt, Dan, when you look at these guidelines, what stands out to you as you're thinking about how you practice, how you all are practicing at your stroke center, and then specifically how we educate our residents, our fellows on what they need to know, particularly the newness of it when it comes to making thrombolysis treatment decisions?

Dr. Dan Ackerman:

With all the discussions we've had in the past, there have been a lot of specifics about certain studies and how they might affect practice, but this guideline really opened up a lot and gave us an opportunity to do things in a way that makes really good clinical sense and really brings a lot of practices that have now become common at some centers into the fore so that we can get that information out to everyone and make sure everyone has that same really high level of stroke care everywhere they go.

I think the first thing that stands out to me is what did not change. And want to reinforce that, particularly for people who are just getting into this, stroke alert is a screening tool, not a severity score. It's not like an MI alert where you do an EKG and you see the tombstone wave and you say, "Oh, there's an MI and we're taking them to treatment." This is a screening tool, so it is meant to be highly sensitive at the cost of being specific.

At our shop for a long time now, we have initiated stroke alert for anyone who presents either within 24 hours of acute onset of neurologic symptoms or has an unknown onset of acute neurologic symptoms and they are still symptomatic to some degree at the time of their presentation, and that's it. We don't make any other statements about how severe something is or what kinds of symptoms someone necessarily has to have. We purposely keep it as broad as possible, again, because we're trying to screen.

And the other thing that has not changed, time is still brain. So with all of these different nuances on how we can treat patients and who might be candidates for intervention, it is still a matter of understanding these guidelines, applying our best evidence, but doing it as quickly as possible to make sure that we are rescuing as much of that ischemic penumbra as we possibly can.

Now, aside from that, in terms of what stands out that is different, I think one of the early things for me are the recommendations for extended time window for IV thrombolysis. So when you look at the original studies, we understand that when you get out beyond four and a half hours, if you just take all-comers, the risk is going to start to outweigh the benefit. But that doesn't mean there's zero benefit or that no one would receive benefit, but it's a question of, well, how do we cherry-pick those patients who may still receive benefit? And there are a few real specifics in the guideline that help us figure that out.

One is for patients who have an unknown time of onset, but they're within four and a half hours of symptom discovery. And for those patients, they would suggest that doing a stat MRI and comparing a DWI lesion with the corresponding area flare to determine if you see DWI hyper-intensity and the flare image is nice and normal, that would suggest that stroke is young enough that it may still be appropriate to treat that patient.

But we would also say for folks who have salvageable ischemic penumbra, so again, brain at risk that is not core yet, who either awoke with stroke symptoms within nine hours from the midpoint of sleep or, and this is the kicker, are within four and a half to nine hours from last known well. So in other words, they may have been symptomatic already for more than four and a half hours. If those patients have an appropriate ischemic penumbra, it may be reasonable to treat them with IV thrombolysis to improve functional outcomes.

Dr. Andy Southerland:

Well, that's all for this Neurology Minute. We hope this vibrant conversation will help all those who are out looking to make the best treatment decisions for their patients, both based on established evidence and most recent evidence in our new guidelines.