Acute Stroke Rescue and Recovery

Transcription

1 Acute Stroke Rescue and Recovery Qaisar A. Shah, MD Director, Neurointerventional and Neurocritical care Nancy Arena Gogal,, RN Manager Cath/EPS/Neuro lab

2 AMH Stroke Program Evolution 1997: Stroke Program Implemented Intravenous thrombolytic administration initiated 1999: Stroke Program Coordinator hired 2004: Received official Primary Stroke Center certification First certified stroke center in Pennsylvania

3 AMH Stroke Program Evolution 2005: Stroke unit achieved 100% staff training NIH stroke scale 2006: Community education and screening with stroke risk assessment soared Annual Achievement Award for the American Stroke Association 2006, 2007, : Developed a second support group focusing on the different needs of the young stroke patient Community Stroke Alert DVD created and distributed

4 AMH Stroke Program Evolution Medical emergency team (MET) trained to identify urgent response to stroke 2008: SIM lab for Emergency Trauma Center (ETC) staff for stroke alert education 2009: Stroke alert notification for ETC staff

5 Introduction of the Service Abington Memorial Hospital is a Joint Commission certified Primary Stroke Center. Since the start of Neurovascular service in July 2008, it has become a Comprehensive Stroke Center Neurovascular Service consists of; Neurointerventional ( 2 Neurointerventionalists) ) & Neurointensive Care (1 Neurointensivist)

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7 Improvement Measures Emergency Medical Services (EMS): Education/Awareness through series of lectures Members of the Stroke committee Modified NIH stroke scale for rapid identification of symptoms on o the field 22 EMS personal are certified in performing NIH stroke scale Early notification to the Emergency Department with the NIHSS Lab draws on the field Peripheral intravenous access Normal saline bolus up to 250 cc Develop database for constant feedback

8 Improvement Measures Emergency Trauma Center (ETC): Education, protocol availability for intravenous and intra-arterial arterial thrombolytic therapy Setup benchmarks Door needle time < 60 minutes Door puncture time < 90 minutes Early notification to the; Radiology (CT scan and the Neuroradiologist) Lab Pharmacy Stroke committee members

9 Improvement Measures Neuroradiology: CTA/CTP for all patients with acute stroke >3 hours using 64 slice CT scanner CB CBF MTT

10 Improvement Measures Cath lab: Develop Neuro cath lab team to treat acute stroke Stroke alert system Thrombolytic (Tenecteplase( Tenecteplase) ) availability in the PYXIS Anesthesia availability Neuro ICU: Fully trained ICU staff with focus on dealing with Neurological emergencies Normothermia protocol, hypertonic saline Work in progress; LICOX (brain oxygen monitoring device)

11 Improvement Measures Stroke Unit: Fully trained neurological nurses All RNs are NIH stroke scale certified

12 Impact: Case Volume (Intravenous and Intra-arterial arterial treatments)

13 Impact: Rapid Evaluation and Rx

14 Prospective Database Total of 28 patients were taken to the cath lab for Intra- arterial treatment of Stroke between July 2008 August 2009 All patients underwent CTA/CTP at baseline Patients with normal head CT and with no mismatch were not treated with further intervention 21/28 patients underwent intra-arterial arterial treatment (seven patients had no arterial occlusion)

15 Prospective Database Neurological improvement was considered if there was 4 4 points decrease in NIHSS within 24 hours Favorable outcome was measured as modified Rankin Scale (mrs( mrs) ) of 2 at 3 months Symptomatic Intracerebral Hemorrhage was considered when there was ICH with worsening of neurological symptoms within first 24 hours (NIHSS 4 points) 6.4% after IV tpa 7-10% after IA tpa Rate of Recanalization,, TIMI grading scale was used TIMI grade 0 = no flow TIMI grade I = partial recanalization with no distal flow TIMI grade II = partial recanalization with good distal flow TIMI grade III = complete recanalization

16 Age Gend er Procedure Baseline NIHSS 24 hr NIHSS Symp ICH Asymp ICH 3 month mrs 67 M TNK Yes 0 88 M TNK, CAS F TNK, MERCI, Balloon 73 M TNK, ICAD stent, CAS Yes M TNK F TNK M ICAD Stent M TNK M TNK, Penumbra M Penumbra, CAS Yes 4 58 M TNK, ICAD stent F TNK, Penumbra

17 Age Gender Procedure Baseline NIHSS 48 M TNK, angioplasty 24 hr NIHSS Symptom atic ICH Asympto matic ICH 3 month mrs Yes 0 88 M TNK, Penumbra F CAS F TNK F TNK M MERCI M TNK M CAS F TNK

18 Procedures Procedure No. Tenecteplase alone 8 Tenecteplase + Mechanical Thrombectomy 8 Mechanical Thrombectomy alone 5

19 Mechanism Mechanism No. (%) Cardioembolic 14 (62%) Atherosclerotic 6 (28.5%) Arterial Dissection 2 (9%)

20 Results Median Age (years) 69 Median NIHSS 18 Neurological Improvement (%) 67% Recanalization (%) 90% Favorable outcome (%) mrs 57% Symptomatic ICH (%) 4.7% Asymp ICH (%) 14% Mortality (%) 9.5%

21 Achievements Because of rapid growth of the program we were able to recruit more staff Started ABINGTON ANNALS which is a scientific institutional journal Annual Neurovascular Conference Weekly stroke rounds, and monthly Neurovascular rounds Develop partnership with neighboring hospitals and provide expedited transfers to Abington Memorial Hospital for comprehensive care