Harold P. Adams, Jr., MD Department of Neurology Carver College of Medicine UIHC Comprehensive Stroke Center University of Iowa

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1 Harld P. Adams, Jr., MD Department f Neurlgy Carver Cllege f Medicine UIHC Cmprehensive Strke Center University f Iwa

2 D nt receive persnal cmpensatin frm cmmercial interests D receive grant supprt frm NINDS Will discuss interventins that are nt apprved r cleared by the FDA

3 Discuss advances in endvascular treatment f acute ischemic strke Discuss assessment f patients with suspected LVO Discuss triage f patients with suspected LVO Discuss impact f changes in strke care fr Iwa and Nebraska.

4 1996: apprval f rtpa fr treatment within 3 hurs f nset f strke 2008: expansin t 4.5 hurs, nt apprved by FDA, guidelines recmmend 2015: success f endvascular therapy fr LVO and strke within 6 hurs : success f endvascular therapy in sme patients with LVO and strke within 24 hurs

5 Pluses Lnger treatment windw Ptential t treat mre patients with strke Imprve utcmes and prevent mrtality Minuses Only 10 15% f strkes are due t LVO Nt all patients with LVO are eligible Requires sphisticated technlgy and physician expertise Limited availability

6 Lcal thrmbsis r emblizatin Majr intracranial artery ICA, MCA, basilar Extensive brain injury Severe neurlgical impairments Pr neurlgical utcme High risk f death

7 Randmized trial testing interventinal thrmbectmy in carefully selected patients up t 24 hrs after strke Criteria 0-20 ml ischemic cre and NIHSS 10 and age 80 years ld 0-30 ml ischemic cre and NIHSS 10, and age < 80 years ld ml ischemic cre and NIHSS 20, and age < 80 years ld

8 Ngueira et al, NEJM, 2017

9 Enrlled patients with strke secndary t large artery cclusin with time windw f 6 16 hurs Endvascular interventin with best medical therapy vs best medical therapy alne University f Iwa had the largest enrllment in the trial

10 Albers et al, NEJM, 2018

11 Albers et al, NEJM, 2018

12 ASPECTS scre Nn-enhanced CT scan 10 areas f interest Middle cerebral artery territry Evidence f ischemia Lw scre (areas f strke) precludes endvascular treatment CT angigraphy

13 Three parameters MTT/TTP CBF CBV Infarct cre Prlnged MTT/TTP Decreased CBF/CBV Ischemic penumbra Prlnged MTT/TTP Mderately reduced CBF Nrmal/Increased CBV

14 Albers et al, NEJM, 2018

15 Intravenus rtpa remains the initial treatment fr all eligible patients within 4.5 hr nset Thse patients with majr vessel cclusin shuld, in parallel, prceed t endvascular thrmbectmy immediately rather than waiting fr assessment f respnses t rtpa Campbell et all, Lancet Neurlgy, 2015

16

17 Variables t assess t predict utcme Age Baseline NIHSS scre Prestrke mrs Previus strke Diabetes Systlic bld pressure Intravenus rtpa Interval t treatment ASPECT scre Lcatin f cclusin CTA cllaterals Venema E et al, BMJ, 2017; 357: 1710

18 Public Recgnitin f strke and calling 911 EMS Rapid respnse Identificatin f strke/ LVO Transfer t apprpriate hspital Lcal hspital Cde strke fr identificatin f strke/ LVO Ptential treatment with rtpa Identificatin f LVO and transfer

19 Mst patients are seen in cmmunity hspitals Emergency medicine r primary care physicians, advanced practice prviders N lcal neurlgy cverage Cnsiderable uncertainty and anxiety abut treatment f strke Issues related t high risk f brain hemrrhage Limited imaging and labratry supprt

20 Mainly in majr hspitals in bigger cities Lng distances fr patients in rural areas Suthern Iwa Nrthwest Iwa

21 Invlves transfers ver lng distances fr treatment Either land r air evacuatin Invlves integratin f EMS, lcal hspital and majr center

22 Cmprehensive strke center: Omaha Primary strke centers: Nrflk Omaha Lincln Kearney Grand Island Bellevue Scttsbluff Nrth Platte

23 Clinical findings may verlap with thse with cclusins f deep penetrating r branch crtical arteries In general, patients with LVO have mre severe neurlgical impairments Cgnitive: aphasia, neglect, stunned Mtr: weakness- arm, hand, face, leg Sensry: lss- arm, hand, face, leg Visin: lss f visin ne side, eyes deviated

24 Aphasia r neglect Cntralateral hemiparesis Ipsilateral gaze palsy Often have dense artery sign n CT

25 Clinical assessment tl fr EMS Test fr arm weakness, aphasia, and neglect Zha et al, Strke. 2018;49:

26 Invlves bypassing lcal hspitals including primary strke centers Majr advantage is saving time t allw early endvascular interventin Imprved neurlgical utcmes Disadvantages Unnecessary transfer nn-eligible patients Delay treatment with rtpa Expensive

27 Lcal hspitals remain fcus f acute treatment Advantages Imprved assessment/diagnsis LVO Imaging t screen fr strke Availability f telemedicine/cnsultatin Treatment with rtpa Availability f air evacuatin Avid transfer f nn-eligible patients Disadvantages Delay transfer f patients Nn-availability f imaging t screen fr LVO

28 Evlving situatin that likely will be clarified in next few years Current: EMS service t identify strke and pssible LVO EMS t cntact lcal primary strke center Describe nature f impairments Advice abut best lcatin fr emergency treatment Pssibly divert t a hspital with endvascular treatment capabilities

29 Primary strke center Clinical evaluatin fr strke and LVO Limited brain imaging Determinatin f eligibility fr rtpa Determinatin f eligibility fr endvascular treatment Arrange air evacuatin f patients with suspected LVO t hspital that can d endvascular treatment

30 Cmprehensive strke center All the duties f primary strke center Available fr telemedicine r telephne cnsultatin and review lcal imaging Clinical and imaging assessments fr eligibility fr endvascular treatment Perfrm endvascular treatment in eligible patients

31 Exciting time Endvascular interventins are saving lives and reducing the mrbidity f strke Develp strategies t speed evaluatin and treatment f patients with LVO Cntinue t treat patients with rtpa Other cmpnents f strke care als remain imprtant

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