ELVO update. Michael Wilder, MD Director, Neurointerventional Program PeaceHealth Sacred Heart Springfield, Oregon
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1 ELVO update Michael Wilder, MD Director, Neurointerventional Program PeaceHealth Sacred Heart Springfield, Oregon
2 Riverbend 24/7 thrombectomy ELVO alert Access PH PACU Anesthesia
3 Goyal et al. Lancet. 2016
4 5 landmark RTCs 2015 Goyal et al. Lancet. 2016
5 5 landmark RTCs 2015 Goyal et al. Lancet. 2016
6 5 landmark RTCs 2015 Meta-analysis: Goyal et al. Lancet. 2016
7 5 landmark RTCs 2015 Meta-analysis: n = 1287 Goyal et al. Lancet. 2016
8 5 landmark RTCs 2015 Meta-analysis: n = 1287 NNT 2.6 Goyal et al. Lancet. 2016
9
10
11 ELVO
12 ELVO Emergent Large Vessel Occlusion
13 ELVO Emergent Large Vessel Occlusion <6 hours from onset
14 ELVO Emergent Large Vessel Occlusion <6 hours from onset Without large completed infarct
15 ELVO Emergent Large Vessel Occlusion <6 hours from onset Without large completed infarct ASPECTS 6
16 ELVO Emergent Large Vessel Occlusion <6 hours from onset Without large completed infarct ASPECTS 6 NIHSS 6
17 ELVO Emergent Large Vessel Occlusion <6 hours from onset Without large completed infarct ASPECTS 6 NIHSS 6 Large vessel occlusion
18
19 All patients still get IV tpa if eligible
20 Every hour of delay leads to 38% decrease in likelihood of good outcome Menon et al. Stroke 2014
21 Door to groin goal 90 minutes
22
23 Earlier involvement of interventionist Prior to CT scans being done CTA head & neck on all stroke alerts
24 Field identification of ELVO
25 Two questions in the field
26 Two questions
27 Two questions 1. Is the patient having a stroke?
28 Two questions 1. Is the patient having a stroke? 2. Does the patient need endovascular therapy? (ELVO)
29 Stroke?
30 Cincinnati Los Angeles You can t teach an old dog new tricks Kidwell et al. Stroke 2000
31 ELVO?
32 Cortical Signs
33
34 Aphasia corexel.com
35 Neglect nature.com
36 Visual field cut casemed.case. edu
37 Gaze palsy pixabay.com
38 RACE
39
40 LAMS
41 C-STAT Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Alteration of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
42 Gaze Conjugate gaze deviation ( 1 NIHSS) Yes 2 points - highest weight in scale No
43 Gaze
44 Gaze Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Level of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
45 Gaze Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Level of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
46 Arm Weakness Arm (right or left or both) falls to bed before 10 seconds ( 2 NIHSS)
47 Arm Weakness
48 Arm Weakness Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Level of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
49 Arm Weakness Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Level of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
50 Level of consciousness Incorrectly answers at least 1 of 2 of LOC questions on NIHSS (age, month) and Does not follow at least one of two commands (close eyes, make a fist) 1 on NIHSS items 1b and 1c
51 Level of consciousness
52 Level of consciousness Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Alteration of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
53 Level of consciousness Item Findings Score Gaze Absent 0 Present 2 Arm Weakness Absent 0 Present 1 Alteration of consciousness Absent 0 Present 1 C-STAT Positive 2 or greater
54 Sensitivity Specificity Positive Likelihood Ratio Negative Likelihood Ratio Severe Stroke NIHSS >15 Moderate Stroke NIHSS > 10 89% 73% % 85% Katz: Stroke 2015;46:
55 EMS training next week Radio in as C-STAT positive if score 2 Page out stroke alert as C-STAT positive Will enable early involvement of interventionist for diagnosis and treatment of ELVO
56 Conclusion Early recognition is key Will allow improved door to groin times
57 Suggestions CTA head and neck on all stroke alerts Alert interventionist prior to imaging if cortical findings and weakness C-STAT Stroke activation order set placed prior to pt arrival
58 Thank you
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