Update on Neurologic Emergencies

Transcription

1 Update on Neurologic Emergencies KAREN GREENBERG, DO, FACOEP ARIA JEFFERSON HEALTH SYSTEM VIRTUA HEALTH SYSTEM KENNEDY HEALTH SYSTEM

2 Disclosures Genentech Speakers Bureau I have disclosed a relevant relationship with Genentech but have resolved this conflict with Abington Jefferson Health System. I have agreed not to promote any products or services of Genentech with which I have a financial relationship.

3 Objectives Review national stroke treatment rates. List benefits and limitations of prehospital stroke scales. Identify pitfalls of acute stroke imaging and opportunities to improve care.

4 Background and Current State Current guidelines for the management of patients with acute ischemic stroke published by the AHA/ASA include specific recommendations for the administration of activase Despite its effectiveness in improving neurological outcomes, many patients with ischemic stroke are not treated with activase, because they arrive late or because of delays in assessment/administration of IV activase

5 Background and Current State Earlier administration of IV activase after the onset of stroke symptoms is associated with greater functional recovery One of the potential approaches to increase treatment opportunities and improve stroke outcomes is to provide this treatment in a more timely fashion after patient arrival (reduce the door to needle time for IV activase)

6 Background and Current State IV activase is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A). Although a longer time window for treatment with activase has been tested formally, delays in evaluation and initiation of therapy should be avoided, because the opportunity for improvement is greater with earlier treatment. Activase should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B).

7 Time to Treatment in Ischemic Stroke Pooled data from 6 randomized placebo-controlled trials of IV activase. Treatment was started within 360 min of onset of stroke in 2775 patients randomly allocated to activase or placebo Odds of a favorable 3-month outcome increased as onset to treatment decreased (p=0.005). Odds were 2.8 (95% CI ) for 0-90 min, 1.6 ( ) for min, 1.4 ( ) for min, and 1.2 ( ) for min in favor of the activase group. The sooner that rt-pa is given to stroke patients, the greater the benefit, especially if started within 90 minutes of symptom onset Hacke, W., G. Donnan, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-pa stroke trials. Lancet 2004;363:

8 Thrombolysis: Number of Patients Needed to Treat (NNT) to Achieve Excellent Recovery (mrs 0-1) 90 mins NNT=4 to 5 By the way this is awesome! 90 min - 3 h NNT= h NNT=14 mrs, modified Rankin Scale Lees et al. Lancet 2010;375:

9 Question What is the goal door-to-needle time to treat a patient with acute ischemic stroke with intravenous activase? a) 30 minutes b) 60 minutes c) 180 minutes (3 hours) d) 270 minutes (4.5 hours)

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11 Question What percentage of acute ischemic stroke patients are actually treated in 60 minutes or less across the United States? a) 10% b) 30% c) 50% d) 70%

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13 Background and Current State Door to Needle and the Golden Hour of Acute Ischemic Stroke Treatment: Starting March 2015, the Joint Commission required DTN of 60 minutes in 50% of all eligible AIS patients receiving intravenous Activase Target: Stroke Phase II has established more aggressive goals: -DTN within 60 minutes in at least 75% of patients -DTN within 45 minutes in at least 50% of patients

14 Question What percentage of all patients with a discharge diagnosis of acute ischemic stroke receive a fibrinolytic as part of their care? a) 3-5% b) 25-27% c) 57-59% d) 80-82%

15 Observed Challenges Discharge data show that a small percentage of all AIS patients receive activase One retrospective study estimated in 2009 between 3.4 to 4.5% of patients (n=279,968) with a discharge code of AIS received a thrombolytic A separate retrospective study estimated that between % of patients (n=323,228) with a discharge code of AIS received a thrombolytic References: 1. Adeoye, O. et al. Stroke. 2011; 42: Kleindorfer D et al. Stroke. 2008; 39: Mullen MT et al. J Am Heart Assoc. 2013, 2e

16 STK-4 is a Widely Used Treatment Rate Measure National mean IQR performance for STK-4 in FY2014 STK-4 is defined as the number of patients treated within 3 hours of time seen normal divided by the number of non-excluded AIS patients arriving within 2 hours of time last seen normal 2 STK-4 excludes patients with documented reasons for not initiating Activase (alteplase) and those not arriving within 2 hours of time last seen normal 2 References: 1. Hospital Compare Database. July 16, Centers for Medicare & Medicaid Services and the Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. 2015:

17 Question What is the current STK-4 treatment rate here at Abington? a) 22% b) 55% c) 78% d) 93%

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19 All-AIS treatment rate provides a broader perspective than STK-4 All-AIS treatment rate provides a broader perspective than STK-4 All-AIS treatment rate measures the percentage of patients with a discharge diagnosis of AIS that were treated with Activase (alteplase) This program is presented on behalf of Genentech and the information presented is consistent with FDA Guidelines. I have been compensated by Genentech to serve as faculty for this program. Please see Important Safety Information throughout and the Please full Prescribing see Important Information Safety available Information this throughout presentation. and the full Prescribing Information available at this presentation Genentech USA, Inc. All rights reserved

20 STK-4 does not account for certain patients with AIS in your hospital STK-4 excludes patients 1 : STK-4 does not account for certain patients with AIS in your hospital With documented reasons for not initiating Activase (alteplase) Patients not arriving within 2 hours of time last seen normal Other reasons STK-4 = # of patients treated with Activase 3 hours of time last seen normal # of patients who arrived 2 hours of time last seen normal This program is presented on behalf of Genentech and the information presented is consistent with FDA Guidelines. References: 1. Centers for Medicare & Medicaid Services and the Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. 2015: I have been compensated by Genentech to serve as faculty for this program. Please 2017 see Genentech Important USA, Inc. Safety All rights reserved. Information throughout and the full Prescribing Information available at this presentation

21 All-AIS treatment rate captures every patient with AIS All-AIS treatment rate: All-AIS treatment rate captures every Every patient is tracked patient with AIS All-AIS = Every patient is tracked # of patients treated with Activase # of patients with a discharge diagnosis of AIS No patients excluded All-AIS treatment rate can provide a deeper insight into your stroke program Note: All-AIS treatment rate can capture both eligible and ineligible patients. For eligible patients, it is important to consider the entire safety profile when making treatment decisions. According to the labeled indication, treatment must be initiated within 3 hours of symptom onset, after the exclusion of ICH as the primary cause of stroke signs and symptoms. This program is presented on behalf of Genentech and the information presented is consistent with FDA Guidelines. I have been compensated by Genentech to serve as faculty for this program. Please 2017 see Genentech Important USA, Inc. Safety All rights reserved. Information throughout and the full Prescribing Information available at this presentation

22 Prehospital Scales for Large Vessel Occlusion - Typical Anterior Circulation large stroke TIME IS BRAIN!! - Quantitative analysis estimated majority stroke completion is 10 hours - Neuron loss: - Per hour: 120 million - Per minute: 1.9 million - Endovascular Every 30 minute delay to reperfusion reduces likelihood of good outcome Saver. Stroke Ribo et al. Stroke 2016

23 Prehospital Scales for Large Vessel Occlusion Currently multiple stroke scales in place to identify LVO prehospital. The 4 most commonly used stroke scales are: 1) Cincinnati Prehospital Stroke Scale (CPSS) 2) Los Angeles Prehospital Stroke Scale (LAPSS) 3) LA Motor Scale (LAMS) 4) Rapid Arterial Occlusion Evaluation (RACE) -RACE score 5 Unfortunately, none of the scales has sufficient accuracy to identify strokes and eliminate stroke mimics. Multiple other tools are being developed to help improve prehospital identification of stroke and LVO. Sequeria et al. Comparison of Prehospital Stroke Scales. Circulation. 2015

24 Prehospital Scales for Large Vessel Occlusion Other stroke assessment tools: - 3 item stroke scale (3I-SS) - Cincinnati Prehospital Stroke Severity Scale (CPSSS) - Prehospital Acute Stroke Severity Scale (PASS) - National Institutes of Health Stroke Scale (NIHSS) - Gaze, Face, Arm, Speech Test (G-FAST) - Legs, Eyes, Gaze, Speech (LEGS) - Melbourne Ambulance Stroke Screen (MASS) - Medic Prehospital Assessment for Code Stroke (Med PACS) - Ontario Prehospital Stroke Screening (OPSS) - Recognition of Stroke in the Emergency Room (ROSIER) - Vision, Aphasia, Neglect (VAN) Teleb et al. Stroke vision, aphasia, neglect (VAN) assessment. BMJ. 2016

25 Prehospital Scales for Large Vessel Occlusion RACE LEGS LAMS VAN 3I-SS CPSSS Need to calculate score Yes Yes Yes No Yes Yes # of tests Sensitivity Specificity

26 Large vessel occlusion screening tools brain view. 3I-SS, 3 item stroke scale; CPSSS, Cincinnati Prehospital Stroke Severity Scale; LAMS, Los Angeles Motor Scale; LEGS, legs, eyes, gaze, speech (Texas Stroke Intervention Prehospital Stroke Severity Scale); RACE, Rapid Arterial occlusion Evaluation Scale; VAN, vision, aphasia, neglect. Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9: Copyright Society of NeuroInterventional Surgery. All rights reserved.

27 Why is all of this important? EMTs are under pressure to decide should acute ischemic stroke patients be taken to the nearest primary stroke center (PSC) or should they bypass the primary stroke center to take the patient directly to a comprehensive stroke center (CSC) with endovascular capabilities.

28 Argument for Nearest Primary Stroke Center Prehospital stroke scales are not measures of stroke severity and lack sensitivity/specificity for diagnosing anterior circulation LVO. Many stroke patients will not have a retrievable LVO and therefore are not eligible for endovascular therapy. -About 10-15% of stroke patients are eligible for clot retrieval Every 15 minute acceleration in start of IV activase results in 4% increased likelihood of independence. If LVO identified, then rapid transport to an endovascular therapy capable center. Southerland et al. Suspected LVO. Stroke. 2016

29 Argument to Bypass Primary Stroke Centers IV activase is not effective in LVO Time is brain: the faster perfusion achieved, the higher the likelihood of a good outcome Endovascular treatment is safe and highly effective Median delay of onset to reperfusion as a consequence of drip and ship compared with mothership was ~ 2 hours in SWIFT-PRIME Bypass Primary Stroke Centers and transport LVO patients directly to a Comprehensive Stroke Center until stroke systems of care improve to ensure Door-In-Door-Out times of < 40 minutes at the PSC Southerland et al. Suspected LVO. Stroke. 2016

30 Putting it all Together: Case #1 54 yo white male last seen normal 30 minutes ago in a local Rite Aid. Pt walked into the store and shortly thereafter, noted to have significant right sided weakness and difficulty speaking. Neuro exam in ED shows left gaze, complete hemiparesis with decreased sensation to right face/arm/leg, severe dysarthria, + expressive aphasia NIHSS 25 PMHx/PSHx/Meds/Allergies: All unknown BP 160/80 HR 85 RR 16 pox 95% RA Accucheck 155 Weight 80 kg

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32 Putting it all Together: Case #2 11:00: Arrival 11:05: CT scan 11:10: Call to teleneurology 11:27: Activase given Door to Needle time 27 minutes!! 11:27: Teleneuro consult done and arranges for transport to mothership/csc 12:15: Pt transferred by helicopter Drip and Ship!!

33 MTT MTT

34 CBF CBF CBV

35 Putting it all Together Case #1 12:56: CTP and CTA at Comprehensive Stroke Center 13:30: Left MCA opened with Solitaire device and flow re-established

36 Success!! 11:00 am to 13:30 pm

37 Putting it all Together Case #2 48 yo female last seen normal 12:30 pm Arrives to Neuro ED at 12:54 pm Arrives with her husband he drove her to ED Blood Sugar 180 Vital signs: HR 88 BP 135/89 RR 16 pox 100% RA Patient weight 72 kg NIHSS 8 -Pt moaning but unable to speak -right facial droop, dec sens right face and RUE

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39 Weight: 72 kg 0.9 x 72 = 64.8 mg Putting it all Together Case #2 10% bolus 6.5 mg over one minute 90% infusion 58.3 mg over one hour Door to needle time: 35 minutes

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43 Putting it all Together Case #2 14:35: Call to neurosurgery for occlusion left superior M2 branch of left MCA, moderate penumbra Patient heads up to intervention suite

44 Success!! 12:54 pm to 15:00 pm

45 Patients with atypical symptoms may be misdiagnosed Signs and symptoms associated with missed stroke diagnosis include: - Headache - Nausea or vomiting - Dizziness - Seizure - Syncope - Difficulty walking Based on a retrospective chart review on all patients with a discharge diagnosis of ischemic stroke between February 2013 to February 2014 at a large certified stroke center and academic teaching hospital that sees > 1000 ED stroke codes each year and a regional referral community hospital that sees 200 ED stroke codes per year. Arch AE, et al. Stroke. 2016; 47:

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47 Pitfalls of Acute Stroke Imaging The initial step in the management of a suspected stroke patient is an imaging examination. This is done by acquiring a nonenhanced CT scan of the brain. Primary role is not to diagnose ischemic stroke or infarction but to identify early signs of ischemia if present and, more importantly, to rule out hemorrhage. Also, conditions that can clinically present with the stroke syndromes (SAH and neoplasm) can be ruled out. Khandelwal, Niranjan CT Perfusion in Acute Stroke. Indian Journal of Radiology and Imaging. 2008; 18 (4):

48 Pitfalls of Acute Stroke Imaging It is well known that a non-contrast CT head is not sufficiently sensitive to diagnose ischemia, especially regarding posterior circulation strokes. Recently, there has been a significant increase in the use of brain MRI in the evaluation of patients with AIS. The rationale for MRI, in particular diffusion-weighted imaging (DWI), in the evaluation of AIS is that this modality has substantially higher sensitiivty (88-100%) than that of head CT for detecting acute ischemia, with a specificity reported to be as high as % Edlow, BL, et al. Diagnosis of DWI-negative acute ischemic stroke. Neurology. 2017,89:

49 Pitfalls of Acute Stroke Imaging Case #3 74 yo male c/o feeling off balance x 3 days. Pt is also c/o right sinus congestion and ringing in the right ear Pt states feels like he is sea sick. No HA, vertigo, vision changes, difficulty speaking or swallowing, localized or lateralized weakness, numbness/tingling. + HTN, + TOB. No DM or high chol VS: 172/ % RA Neuro: GCS 15, CNs 2-12 intact, 5/5 muscle strength all limbs, sens intact, normal speech, normal finger to nose, normal heel to shin, + unsteady/staggering gait with ambulation. NIHSS zero

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51 DWI ADC

52 Pitfalls of Acute Stroke Imaging Case #3 Critical Stenosis of right carotid found on MRA as well Pt was discharged to subacute rehab (Remember NIHSS was zero!) Scheduled for CEA one month

53 Pitfalls of Acute Stroke Imaging Case #4 68 yo male c/o right leg from knee down feels numb and weak since 0330 am. Pt states I don t feel right. He is on prednisone x 8 days for poison ivy Pt went to sleep 2300 and felt normal. Woke 0330 to go the bathroom and states right leg weak and numb from knee down. It is now 0900 in the ER. No HA, vision changes, difficulty speaking or swallowing. + HTN, + high chol. No DM, No TOB VS: 136/ % RA Neuro: CNs 2-12 intact, 5/5 strength all limbs including RLE, mildly dec sens to RLE, normal finger to nose and heel to shin, normal speech, normal gait. NIHSS 1

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55 DWI DWI ADC ADC

56 Pitfalls of Acute Stroke Imaging Case #4 Pt discharged to home with outpatient physical therapy

57 Pitfalls of Acute Stroke Imaging Parting thought and scary stuff... There is emerging evidence that DWI fails to identify AIS in a substantial minority of patients. These DWI-negative stroke cases broadly fall into 3 categories: 1) Posterior circulation ischemia is associated with DWI negativity 2) Small strokes, particularly in the brainstem, may evade detection by DWI 3) Hyper-acute ischemia (within 6 hours of symptom onset) underestimated or missed by DWI Edlow, BL, et al. Diagnosis of DWI-negative acute ischemic stroke. Neurology. 2017,89:

58 Questions and Discussion