Where are we heading and where are the big challenges?

Transcription

1 Where are we heading and where are the big challenges? Christopher Levi Neurologist, John Hunter Hospital, Newcastle & Liverpool Hospital, Sydney Executive Director, Sydney Partnership for Health Education Research & Enterprise

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5 Principles 1. Equity 2. Social justice & fairness 3. Empowered communities 4. Elimination of conditions that cause harm Health care professionals have a key role as we - Care about and care for people, communities, societies Have imagination and curiosity Can generate new knowledge and ideas Can implement and translate new knowledge

6 Your Stroke Strategy will play a role to influence State Health, National Health and Planetary Heath

7 Stroke well positioned to contribute Large burden of disease and high community cost Very effective and highly cost-effective preventive options BP lowering, Antithrombotics, Statins Now very effective and highly costeffective treatment options Stroke units, Reperfusion

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14 Grand challenges Close the gap Improve stroke prevention implementation Further build an expert stroke care workforce including a clinical academic workforce Aim for universal access to modern comprehensive acute stroke care Improve implementation of intravenous thrombolysis for all who are likely to benefit Build endovascular clot retrieval for an increasing number and for those who are likely to benefit Improve access to effective stroke prevention for those with TIA and stroke

15 Prevention

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17 TIA MS FRONT LOADED RISK Earlier assessment and earlier treatment reduces risk of recurrent stroke at 90 days Peter Rothwell EXPRESS study Lancet 2007

18 Contemporary event rate post -TIA

19 Are we asking - How are we tracking in secondary prevention? Where are the opportunities for improvement? What are we doing about it? Are we improving?

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26 Hospital based care

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28 A collaborative national effort to monitor, promote and improve the quality of acute stroke care. Developed using national operating principles and technical standards for clinical quality registries

29 Become More Programmatic Set the end-game set the targets & measure Pick your targets Refresh the State Stroke Plan around the targets eg. Workforce targets in PARTNERSHIP Organized stroke care access and facilitated access to 90%+ Organized reperfusion therapy access - and facilitated access tpa 20% Organized TNA/TIA prevention access and facilitated access

30 Workforce building opportunistic to programmatic

31 Establish high performing stroke care teams & networks

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33 Acute stroke care networks Nature Reviews Neurology 9, (June 2013) doi: /nrneurol

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37 Non-precision stroke medicine

38 Model Predicted Concentrations for 0.25 mg/kg bolus and Median Activase Concentrations (USPI Dosing) 1000 Subject Simulation 7000 Concentration (ng/ml) Model Predicted Activase Median 0.25 mg/kg 5th Percentile 0.25 mg/kg Median 0.25 mg/kg 95th Percentile Time (min)

39 Collaterals strongly influence penumbral life expectancy

40 Precision stroke medicine CTP Current practice advanced imaging selection Perfusion measures are predictive of tissue fate in various specific circumstances RCTs & cohorts treated with iv lytic RCTs & cohorts treated with endovascular reperfusion Perfusion measures MAY be able to be used as decision rules to avoid futile reperfusion therapy and avoid risk of harm from reperfusion therapy

41 Penumbral profiling Snapshots of dynamic pathophysiology Penumbral loss occur most rapidly when residual flow lowest (ie. minimal antegrade flow and poor collaterals) BUT onset to reperfusion time ALONE is not a good predictor of outcome

42 MR mismatch defined ischaemic penumbra Placebo tpa

43 HUMAN EXPERT NCCT & CTA expert review and assessment of occlusion site and collateral status 5 minutes Off-trolley to acquisition time 5 minutes NCCT/CTA 10 minutes NCCT/CTP/CTA 25 minutes MRI Flair/DWI/PWI AUTOMATED SYSTEM Acquisition completion to automated perfusion map processing 5 minutes Perfusion Map dispatch to or PACS 3 minutes

44 Mobile on-line patient profiling for reperfusion suitability

45 Mobile on-line patient profiling for reperfusion suitability The stroke physician has to learn some new tricks and interpret the combination of qualitative and quantitative information now available - Time frame, clinical picture, depth and extent of ischaemia, core volume, collateral status.

46 MBH Telethrombolysis 86M NIHSS 11 mrs 1 pre-stroke GS /3/15 Symptom onset Left sided weakness after waking Door 1014 (SO +134) DTI 38 (SO +172) DTD 65 (SO +199) - open-label alteplase HTN Chol Skin cancer resected from left leg several weeks ago (no graft) 24 hours NIHSS 4 Discharged home

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49 Main Issues IMS3 Workflow delays onset to IA therapy commencement >4h Onset to recanalization 5h+ Relatively poor recanalization/reperfusion with old devices only 30-40% TICI2b/3 IMS3 No proof of vessel occlusion No use of tissue viability measures only 56% good NCCT scans by ASPECTS

50 HERMES Collaborators Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke trials (HERMES) OR 2.49 ( , p<0.0001) no symptoms dead Goyal et al, Lancet 2016

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54 7.3 hour onset to groin puncture time window for EVT? NNTs hrs

55 Grand challenges Improve stroke prevention implementation Further build an expert stroke care workforce including a clinical academic workforce Aim for universal access to modern comprehensive acute stroke care Improve implementation of intravenous thrombolysis for all who are likely to benefit Build endovascular clot retrieval for an increasing number and for those who are likely to benefit Improve access to effective stroke prevention for those with TIA and stroke

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