CVA Updates Karen Greenberg, DO, FACOEP. Director Neurologic Emergency Department Crozer Chester Medical Center

Transcription

1 CVA Updates 2018 Karen Greenberg, DO, FACOEP Director Neurologic Emergency Department Crozer Chester Medical Center

2 Disclosure I have the following financial relationship with the manufacturer of any commercial product and/or provider of commercial services discussed in this CME activity: Speakers bureau for Genentech I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3 Objectives 1) Review 2018 Guidelines for the Early Management of Acute Ischemic Stroke 2) Describe the ever changing landscape of CVA management 3) Examine the literature of Neuro Intervention in the ED

4 Highlights from 2018 Guidelines - Stroke is the No. 2 cause of death worldwide and the No. 5 cause of death in the U.S. - Establish door-to-needle times within 60 minutes in 50% or more of stroke patients who are treated with IV alteplase, with secondary door-to-needle times within 45 minutes encouraged - All patients who are eligible for IV-alteplase should receive it, even patients being considered for mechanical thrombectomy Power WJ, Rabinstein AA, Ackerson T, et al; for the AHA Stroke Council Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the AHA/ASA. Stroke. 2018

5

6 Highlights from 2018 Guidelines BP Management For AIS patient who... Have comorbid conditions requiring BP reduction - Did not receive IV alteplase or endovascular treatment - Do not have a comorbid condition that requires acute antihypertensive treatment Receive IV alteplase Are undergoing mechanical thrombectomy Recommendation Early hypertension treatment to lower BP by 15% is probably safe - If BP is < 220/120 mmhg, treatment of hypertension within the first hours after an AIS is of no benefit - If BP is 220/120 mmhg or higher, the benefit of lowering BP is unknown, but lowering by 15% in the first hours after an AIS is reasonable BP should be maintained below 180/105 mmhg during and for 24 hours after the administration It is reasonable to maintain BP below 180/105 mmhg during and for 24 hours after the procedure

7 2018

8 Tenecteplase vs Alteplase Before Endovascular Thrombectomy (EXTEND-IA TNK): A multicenter, randomized, controlled trial - Hypothesis that tenecteplase would increase reperfusion at initial angiogram compared to alteplase - TNK 0.25 mg/kg, max 25 mg or alteplase 0.9 mg/kg, max 90 mg patients, Australia - TNK was superior to alteplase doubling the incidence of prethrombectomy reperfusion. Symptomatic hemorrhage was rare and did not differ between lytics. TNK is a more effective option for pre-thrombectomy thrombolysis Campbell BC, Mitchell PJ, et al; ISC Los Angeles, CA. Jan 24, 2018.

9 Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals with Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients with AIS - LVO prediction instruments, based on stroke signs and symptoms, have been proposed to identify stroke patients with LVO for rapid transport to endovascular thrombectomy capable hospitals. - Most frequently studied prediction instrument was NIHSS - No scale predicted LVO with both high sensitivity and high specificity. System that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. - Smith EE, Kent DM, et al. Stroke. Jan 24,2018

10 The Effect of Rivaroxaban with Aspirin on Stroke Outcomes in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) Trial - COMPASS compared the results of rivaroxaban alone or combined with aspirin in patients with atherosclerosis in 27,000 participants. - Significant reductions in stroke were noted in individuals assigned to rivaroxaban 2.5 mg bid plus ASA 100 mg daily compared with ASA alone. - Rivaroxaban with ASA is associated with fewer ischemic strokes and a higher likelihood of disability-free status at 7 days without a significant increase in hemorrhagic strokes. The risk of ischemic stroke in high-risk patients was nearly halved. - Sharma M, Eikelboom JW, et al. ISC Los Angeles, CA. January 24, 2018

11 Closure of Patent Foramen Ovale Vs Medical Therapy in Patients with Cryptogenic Stroke or Transient Ischemic Attack patients with 3.7-year mean follow up RA PFO LA - In patients with cryptogenic stroke/tia and PFO who have their PFO closed, ischemic stroke recurrence is less frequent compared with patients receiving medical treatment. Atrial fibrillation is more frequent but mostly transient. There is no difference in TIA, all-cause mortality, or myocardial infarction. Ntasios G, Papavasileiou V, et al. Stroke. January 15, 2018

12

13 Broderick, JP. Neurology Reviews February;25(2):21-22 Benefit of Neuro Intervention 6-24 Hour Window 4 trials looking at whether thrombectomy is effective in appropriately selected patients if administered at more than 6 hours from onset. Getting away from chronological measures of infarction to physiological measures of brain ischemia. Think tissue clock instead of time clock.

14 DAWN Trial Diffusion Weighted Imaging (DWI) or Computerized Tomography Perfusion (CTP) Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention (DAWN) Subject can be randomized within 6 to 24 hours after time last known well Clinical Imaging Mismatch (CIM) demonstrated on MR-DWI or CTP maps Occlusion of the intracranial ICA and/or MCA-M1 as evidenced by MRA or CTA ClincalTrials.gov

15 DAWN Trial Presented European Stroke Organization Conference (ESOC) May 2017 Trial ended early due to positive outcomes after just 200 patients. Investigators utilized stent retrievers including Solitaire and Trevo devices and assessed primary outcome of mrs >2 at 90 days Results showed a 2-point difference in the 90-day weighted MRS score in favor of the thrombectomy group, which translated into a 73% relative reduction of dependency in ADLs and a NNT of 2 for any lower disability Hughes. DAWN: Thrombectomy Effective Up to 24 Hours After Stroke. Medscape. May 2017

16 DEFUSE 3 - Endovasc tx plus medical therapy vs medical therapy alone hour window - Imaging CTP/CTA or MRI DWI/PWI/MRA - Better functional outcomes if endovascular plus standard medical therapy Albers GW, Marks MP et al. Thrombectomy for Stroke at 6 to 16 hours with selection by perfusion imagaing. NEJM. Jan 24, 2018

17 New Trials in the Works Trial Time Window Primary Endpoint Imaging Purpose CRISP Target mismatch vs no target mismatch >6 hours NIHSS 30 days CTP Develop practical tool to identify acute stroke pts who are likely to benefit from endovasc tx POSITIVE Endovasc tx plus medical tx vs medical tx alone 6-12 hours mrs 3 months CTP/CTA or MR DWI/PWI/MRA assess the safety and effectiveness of the mechanical thrombectomy (physically removing a blockage in a blood vessel) compared to best medical therapy

18 Putting it all Together 76 yo female last seen normal 2300 last night when she went to sleep, it is now 0930 am -pt is from home (prestroke mrs 0) Neuro exam: somewhat sleepy, partial gaze to right, + left facial droop, LUE/LLE drift, + dysarthria, + neglect NIHSS / % RA POC glucose 184 Weight 71 kg Meds: ASA, metoprolol, glucophage, pravastatin Plan: Quad study all at once: CT, CTP, CTA head, CTA neck

19

20 MTT

21 CBF CBV

22

23 Putting it all Together Call to Neurosurgery for occlusion right M1 extending into M2 proximal branches, positive penumbra Neurosurgeon comes to discuss risk/benefit of neuro intervention Patient heads up to intervention suite about 11 hours from time last known well

24 Success!!

25

26 Summary In 2018, All patients who are eligible for alteplase should receive it, even patients being considered for mechanical thrombectomy Several exciting trials broke at International Stroke Conference in January, stay tuned... There is a changing paradigm of tissue clock rather than time clock.

27 Questions and Discussion Questions & Discussion THANK YOU!!!