Like a ticking clock, the onset of stroke activates a chain of dangerous events that end only after nature takes its devastating course or effective medical interventions occur.

Time becomes the enemy, with the first 48 hours critical to the patient's well-being.

This narrow window of opportunity helped drive a University of Iowa Hospitals and Clinics neurologist to play a leadership role in updating American Stroke Association guidelines for treating patients affected by ischemic strokes. The newest guidelines were published in a recent issue of Stroke, a journal of the American Heart Association.

The guidelines revise and supplement those that were written in 1994 and 1996. Aimed at primary care physicians, emergency medicine physicians, neurologists, and others who provide acute stroke care, the guidelines discuss how to manage the neurological and medical problems that can complicate patient recovery.

Harold P. Adams Jr., M.D., chair of the panel that authored the guidelines and professor of neurology in the UI Roy J. and Lucille A. Carver College of Medicine, said the time had come to review the state of acute stroke care.

"Considerable research in stroke has been done in the last decade, and the guidelines for physicians need to reflect the new information," he said.

Some of the recent research has investigated neuroprotective agents to prevent stroke damage, methods to induce hypothermia to reduce fever and prevent stroke damage, clot busting drugs and techniques, imaging techniques to diagnose ischemic stroke, and surgical interventions.

While the advances are considerable, Adams said, much additional work needs to be done. "In this statement, we re-emphasize the potential use of tPA (tissue plasminogen activator) for emergency intravenous management of carefully selected patients who could be treated within three hours of ischemic stroke."

Giving tPA within three hours of stroke onset is the only U.S. Food and Drug Administration-approved treatment for ischemic stroke.

Among their recommendations, the panel noted:

• A regional or local organized program to expedite stroke care can increase the number of patients treated.
• Because time is of the essence, institutions should have diagnostic equipment and staff available 24 hours a day, seven days a week or consider transferring stroke patients to a better-equipped facility.
• To date, no other clot-busting agent has been established as a safe and effective alternative to tPA.
• Intra-arterial thrombolytic therapy, a catheter-based treatment that delivers a clot-dissolving drug to the precise location of the brain blockage up to six hours after symptom onset, holds promise but its effectiveness has not been established.
• Anticoagulants, such as heparin, are not indicated for most ischemic stroke patients.

UI Health Care neurologist leads the latest update of national guidelines on ischemic stroke

Risk factors you can change

• High blood pressure
• Smoking
• High cholesterol
• Physical inactivity
• Obesity
• Alcohol abuse
• Drug abuse