Stroke Center Certification

Stroke is a leading cause of morbidity and mortality in the United States. The Center for Disease Control and Prevention (CDC) reports that over 795,000 people in the United States suffer a stroke each year and that approximately 140,000 of these are fatal. The annual cost of health care services, medicines, and missed days of work in the United States due to stroke is $34 billion. Yet despite these alarming figures, studies have shown that many patients suffering a stroke are not treated in accordance with recommended stroke treatment guidelines. The creation of stroke centers, and a corresponding stroke center certification, aims to improve access to and quality of stroke care nationwide. Stroke treatment has been an area of rapid development and progress over the past 2 to 3 decades, and recent studies continue to shape our management practices. The mainstay of acute ischemic stroke (AIS) treatment has been thrombolytic therapy with intravenous (IV) recombinant tissue plasminogen activator (tPA) since the approval of alteplase by the Food and Drug Administration in 1996. This treatment has been especially effective in treating strokes due to small vessel occlusions, but much less effective in treating strokes due to large vessel occlusions (LVO). Unfortunately, LVO strokes are traditionally the most devastating in terms of morbidity and mortality. Recently, however, studies published since 2015 have shown significant benefit for LVO strokes with specialized endovascular therapies including mechanical thrombectomy.[1][2][3][4] These exciting new therapies have revolutionized modern stroke care for LVO and made mechanical thrombectomy a new standard of care. This paradigm-changing intervention makes provider understanding of stroke center certification levels and capabilities of the utmost importance. [5][6][7][8] The more time brain tissue remains ischemic, the worse the patient's neurological outcome. This concept is known as "time is brain." To improve outcomes, IV tPA should be administered as soon as possible from the onset of stroke. Early administration of IV tPA is associated with improved functional outcomes, decreased hemorrhagic conversion, and decreased in-hospital death. Every 15-minute delay in initiating tPA is associated with patients having 4% worse odds of walking independently at hospital discharge, 3% worse odds of being discharged to home (versus rehabilitation facility or institution), 4% greater odds of death before discharge, and 4% greater odds of experiencing symptomatic hemorrhagic transformation of the infarct.[9] For LVO, the importance of early intervention is also critical in patients undergoing mechanical thrombectomy. Each 1-hour delay in mechanical thrombectomy reperfusion is associated with increased disability and decreased functional independence.[10] The American Heart Association (AHA) and American Stroke Association (ASA) 2018 guidelines recommend IV tPA be administered to all eligible patients as early as possible and within 3 hours of last known normal with an extended window of 4.5 hours in a more selective group of patients. Mechanical thrombectomy is also recommended as early as possible to eligible patients with LVO within 6 to16 hours of last known normal. Mechanical thrombectomy is considered reasonable in select patients within 6 to 24 hours of last known normal.[11] Given these recommendations, it is critical for healthcare providers to have an understanding of stroke center certification levels and capabilities so that timely and appropriate treatment is initiated.