Benjamin Fox, MD Medical Director: Neurointerventional Radiology (NIR) DRMC Medical Director: Neurosurgery & Neurovascular, Intermountain Healthcare

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1 Update on neurointerventional (NIR) services at Dixie Regional Medical Center and in the Southwest Region Benjamin Fox, MD Medical Director: Neurointerventional Radiology (NIR) DRMC Medical Director: Neurosurgery & Neurovascular, Intermountain Healthcare

2 Stroke Facts - 2 nd lead cause of death worldwide - 5 th leading cause of death in the US - Leading cause of preventable disability - 795,000 have a stroke every year - Someone in the US has a stroke every 40 seconds - Stroke kills nearly 129,000 people a year - Stroke kills more women than breast, ovarian, uterine, and cervical cancer combined!

3 Types of Strokes

4 Sytemic Local IV tpa Chemical Thrombolysis Dose: 0.9 mg/kg (maximum of 90 mg) infused over 60 min 10% of the total dose administered as bolus over 1 minute. IA tpa Plasminogen activators catalyze the conversion of plasminogen to the fibrinloytic compound plasmin

5 Timing of Recanalization with IV tpa measured by Transcranial Doppler minutes to recanalization

6 Realities of IV tpa for Stroke Scientifically well established, safe, improves outcome Under-utilized (time constraints) Less than 5 % of stroke patients receive IV TPA Most patients present beyond 4.5 hours Window = hours Largely ineffective for large vessel occlusions (LVO) Only 14% of ICA occlusions and 55% of MCA occlusions recanalize with IV tpa at 24 hrs Among patients with LVOs, 60-80% die within 90 days or do not regain functional independence despite IV tpa Rha et al, Stroke, 2007 Broderick et al, NEJM, 2013 Berkhemer et al, NEJM, 2015

7 Small Vessel Occlusion Large Vessel Occlusion

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9 Compare blood supply to the brain with a sprinkler system Main Line

10 Compare blood supply to the brain with a sprinkler system Main Line The site of blockage determines location and how much grass is affected

11 Small Vessel Occlusion Large Vessel Occlusion

12 Amount of dead grass depends on how long the blockage has been there Main Line If the blockage is reversed before The grass cells die, then the grass Returns green. If the grass is dead, without water too long You have to re-seed it. (Can t do that with the brain)

13 FDA approved devices Merci retriever 2004 Penumbra 2007 SOLITAIRE 2012, 61% vs 24% (TIMI 2 or 3) TREVO2 2012, 86% vs 60% (TICI 2 or 3)

14 Solitaire FR Revascularizatio n Device Covidien / EV3

15 *tpa alone vs tpa + thrombectomy *CTA confirmed large vessel occlusion *IA treatment within 6 hours

16 DRMC Neurointerventional (NIR) Program

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19 New Intermountain Healthcare Stroke Intervention Video Chuck s Story =307a883a6648fa78df8f36ddfc161d33&download

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21 DRMC NIR Services Available Angiography Acute Stroke intervention IA tpa Mechanical Thrombectomy Carotid artery stent angioplasty Vertebral artery stent angioplasty Tumor Embolization Aneurysm treatment (ruptured/unruptured) Coil embolization Pipeline embolization device Arteriovenous Malformation (AVM) and arteriovenous fistula (AVF) embolization

22 DRMC NEUROINTERVENTIONAL / INTERVENTIONAL NEURORADIOLOGY DRMC Joint Commission Primary Stroke Center /7 ER and Hospital NIR stroke intervention call coverage (2) First Hospital in the Intermountain Healthcare system to use Pipeline Embolization device (flow diverter) for treatment of intracranial aneurysm. Only DRMC and IMED perform coil embolization of aneurysms in addition to craniotomy (surgery)

23 Pipeline Embolization device

24 Neurosurgery Case Complexity based on Coding Case Mix Index Severity of Illness Risk of Mortality DRMC IMC MDH UVRMC * Information obtained form Intermountain Coders

25 ANY QUESTIONS?