Acute Stroke Identification and Treatment
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- Christal Dawson
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1 Acute Stroke Identification and Treatment James S. McKinney, MD, FAHA Medical Director, NHRMC Stroke Center SE NC is located in the buckle of the Stroke Belt, seeing the highest stroke incidence and mortality rates in the country. Pathophysiology of Acute Ischemic Stroke 1
2 Goals of Therapy Goal of Acute Stroke Therapy Restore / increase blood flow and oxygen delivery to ischemic tissue as quickly as possible Avoid / limit adverse effects of therapy Prevent recurrent ischemia Stroke: Time is Brain J.R. Marler et al. Neurology 2000;55: by Lippincott Williams & Wilkins Neocortexloses 31million neurons per year in normal aging Every minute of a large vessel stroke, the average patient loses 1.9 million neurons 14 billion synapses 12 km of axonal fibers Stroke Jan;37(1):263 2
3 Current Therapeutic Options IV tpa PROACT II IA tpa Angioplasty Stenting MERCI Penumbra Bridging IV/IA IV tpa (4.5h) Solitaire Trevo Generation 1 Generation 2 Gen 3 FDA Approved Off label Red 2012? STEMI Trauma Stroke Time Dependent Emergencies 3
4 Stroke System Plans Stroke Ready Hospital Primary Stroke Center (PSC) Air Transfers Comprehensive Stroke Center (CSC) Or intvn capable Direct Presenters Short Scene Times Trauma: Load and Go Scene time 10 minutes STEMI: Scene time < 15 minutes Stroke: Scene time < 15 minutes Stroke Screening Tools 4
5 Helsinki Model 1. Ambulance pre notification to stroke team with patient details 2. Patients taken directly to CT scanner on stretcher 3. tpa administered at CT immediately after imaging Pit Stop and Handoff: Transfer Straight to CT Procedure in place for transfer straight to CT Improve door to CT Improve door to tpa Pit Stop Rapid assessment ABCs Handle any quick registration requirements Hand off blood drawn by, or draw labs if needed Begin neuro exam as patient is moved to CT 5
6 Impact of Pre hospital Activation 80 NHRMC Stroke: Number Treated with t PA and Median Door to Needle (a) (a) * 2017 treatment rate annualized based on Jan June Impact of Pre hospital Activation RWJ Experience January 2009 June Brain Attacks (114 Prenotification vs. 115 w/o) Prenotification significantly reduced all stroke time targets Those with prenotification were: Older (Age, median 69.5 vs. 61.5, p=0.002) Sicker (NIHSS 11.1 vs. 6.9, p=<0.0001) More likely to get tpa (27% vs. 15%, p=0.024) McKinney et al. J Stroke Cerebrovasc Dis 2013 Impact of Pre hospital Activation 160 NHRMC Stroke: Number Treated with t PA and Median Door to Needle (a) Number Treated with tpa Door to Needle (minutes) 6
7 Many Do Not Respond Several studies suggest low recanalization rates for proximal large vessel occlusions Distal MCA: 50% recanalization, 52% good recovery Prox MCA: 30% recanalization, 25% good recovery Distal ICA: 5.9% recanalization, 18% good recovery Basilar: 30% recanalization, 25% good recovery Recanalization 0 Distal MCA Proximal MCA Distal ICA Basilar Good Recovery Stroke 2007;38;948 Embolectomy with Solitaire Device for Large Vessel Occlusion (LVO) Good outcomes from Endovascular Trials Trial Intervention (n=233) %mrs0 2 Control (n=267) % mrs 0 2 Adjusted OR (95% CI) MR CLEAN ( ) ESCAPE ( ) SWIFT PRIME ( ) EXTEND IA (1.4 12) REVASCAT ( ) 2 4 fold increase in odds of having a good outcome from a severe stroke with endovascular therapy 7
8 Stroke System Plans RACE 4 or 5? Stroke Ready Hospital Primary Stroke Center (PSC) Air Transfers Comprehensive Stroke Center (CSC) Or intvn capable Direct Presenters Code ELVO 73yo wf brought to ED with suspected stroke Prenotification by On exam NIHSS 17 + neglect, left hemiparesis Emergent CT/CTA R MCA occlusion IV tpa initiated in scanner Code ELVO initiated after CTA 8
9 Code ELVO Making a Difference & Leading Our Community to Outstanding Health tpa in 26, Revascularization in 79. NIHSS 14 > 0. Discharged day 3. 9
10 NHRMC recognized for superior outcomes in the care and treatment of stroke 10
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