Acute Stroke Treatment KPNC Stroke EXPRESS

Transcription

1 Acute Stroke Treatment 2018 KPNC Stroke EXPRESS EXpediting the PRocess of Evaluating & Stopping Stroke 1 Jeffrey G. Klingman, MD The Permanente Medical Group

2 Stroke Treatment in the old days Prior to 1996: back corner of Emergency Department

3 1996: Revolution in Stroke Treatment : IV t-pa ; IV alteplase (t-pa) < 3 hours Number Needed to Treat (NNT) = 4 to prevent major disability Faster is better

4 2011: IV Alteplase to 4.5 hours 2011 IV Alteplase window expands to 4.5 hours No benefit beyond 4.5 hours

5 2013: Endovascular Stroke Treatment (EST) does NOT work 2013: 3 studies - no benefit to endovascular treatment vs IV alteplase N Engl J Med 2013 MR RESCUE Embolectomy was not superior to standard medical care in patients with either a favorable penumbral pattern or a nonpenumbral pattern IMS III Randomly assigned eligible patients who had received intravenous t-pa within 3 hours after symptom onset to receive additional endovascular therapy or ntravenous t-pa alone. The study was stopped early because of futility SYNTHESIS Endovascular therapy is not superior to standard treatment with intravenous t-pa.

6 2016: EST does work (in selected patients) 2016: 4 studies show benefit of endovascular treatment in some stroke patients up to 6 hours Still time sensitive Many fewer patients qualify Difference from 2013 was patient selection and devices

7 2018: The Window Extends : 6 to 24 hours 2018: DAWN and DEFUSE - 3: benefit to 6-24 and 6-16 hours in highly selected Large Vessel Occlusion (LVO) patents NNT 2-3 DAWN DEFUSE 3 Hours Rankin < 2 < 3 NIHSS > 9 > 5 CTA LVO in M1 or ACA LVO in M1 or ACA Core < 70ml on advanced imaging <70ml AND mismatch ratio of >1.8 AND penumbra of >15ml on advanced imaging

8 What would it take to Achieve world class (15-20 minutes) door to needle (DTN) times? Obtain very rapid CT angiogram (CTA) performance and interpretation? Treat, evaluate, and transfer for endovascular therapy very quickly 8

9 Stroke EXPRESS: Key Components Early Stroke Neurologist Video Engagement Rapid assessment Early alteplase ordering Processes redesigned for maximal efficiency Direct to CT and CTA Alteplase administered in CT suite Nearly all patients receive a CTA Rapid Transfer for EST If potential candidate for EST, ambulance pre-ordered before CT/CTA completed Stroke. 2018;49:

10 Population evaluation by teleneurologist Early Stroke Neurologist Video Engagement Every patient is seen and evaluated on arrival by teleneurologist Standardized searchable notes including Stroke alerts cancelled on arrival and why Strokes treated and outcomes including NIHSS exam Presence and location of LVO Transfers for EST

11 Results

12 Results

13 True or False? More patients are eligible for treatment with IV alteplase than are treated with endovascular therapy. A. True B. False Endovascular Therapy IV alteplase 0% 0% True False Response Counter 20

14 Endovascular therapy is rare 18 acute strokes were evaluated to find 1 patient eligible for EST 2546 patients eligible for acute stroke treatment were identified and brought to us by paramedics. Of these patients, 1241 (48.7%) had acute strokes. 600 Treated with IV Alteplase (4X as many as EST) Of the acute strokes, 638 (25%) were potential candidates for endovascular treatment (NIHSS >7) Of these, 141 patients (5.5% of total / 22% of high score) ended up actually having large vessel occlusion and received endovascular therapy.

15 What about the extended window patients? Unknown number of patients will qualify for treatment Nobody has reported number screened for DAWN or DEFUSE 3 EXTEND IA found 70 candidates for treatment out of 549 patients with LVO (13%) 1.7% of all stroke patients (45/2667) qualified for DAWN criteria in one recent study Systems of care need to be prepared to screen potential late window patients Last known well Baseline Rankin NIHSS > 5 (or >9) CT shows no bleed CTA shows occlusion CTP (or MRI) shows small core / perfusion mismatch

16 Endovascular Stroke Treatment Time is brain / faster is better EST is an infrequent, highly specialized treatment Many more patients need IV alteplase than EST (80%) Not all centers should do EST Like may procedural specialties experience and volume matters Minimum 30 treatments per centers per year and 12 per doc per site Rapid identification of EST, patient selection, and transfer is the key

17 Conclusions Acute stroke is a treatable condition Time is critical High functioning primary stroke centers are the key to successful treatment Rapid clinical evaluation Rapid IV alteplase Rapid CTA (Rapid CTP / MRI for late presenting patients) Rapid transfer of selected patients to endovascular treatment centers High functioning Endovascular Stroke Treatment Centers Expedited patient acceptance Adequate volume Excellent treatment times and results