Optimizing Care for Patients with Acute Ischemic Stroke Thrombolytic Therapy for Low NIHSS

Optimizing Care for Patients with Acute Ischemic Stroke Thrombolytic Therapy for Low NIHSS Nerses Sanossian, MD, FAHA Presentation not eligible for CME credit

Disclosures

Today s objectives

Case study: Mary, a 45-year-old Caucasian woman

Every minute counts for patients with AIS

Discussion question DEEP D I V E What are the routing considerations for patients with a suspected stroke? Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation.

AHA/ASA recommendations for EMS routing of patients with a suspected stroke DEEP D I V E The AHA/ASA recommends patients with a positive stroke screen and/or a strong suspicion of stroke should be transported rapidly to the closest healthcare facilities that can capably administer IV alteplase. 1 Class I recommendation, Level of Evidence B-NR The AHA/ASA also states that when several IV alteplase capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. Further research is needed. 1 Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation. AHA/ASA=American Heart Association/American Stroke Association; NR=nonrandomized. Reference: 1. Powers WJ, et al. Stroke. 2018;49:e46-e110.

Considerations for EMS routing of patients with suspected stroke DEEP D I V E The 2018 AHA/ASA Guideline has no recommendation for an EMS routing algorithm due to insufficient evidence, but states that the Mission: Lifeline Stroke algorithm may be a reasonable guideline in some circumstances. 1 FOR PATIENTS WITH A SUSPECTED LVO THAT WERE LAST SEEN NORMAL <3 HOURS AGO* 2,3 : Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation. ASRH=acute stroke ready hospital; CSC=comprehensive stroke center; LVO=large vessel occlusion; PSC=primary stroke center.. References: 1. Powers WJ, et al. Stroke. 2018;49:e46-e110. 2. AHA/ASA Mission: Lifeline Stroke program. Severity-based stroke triage algorithm for EMS. Published 2017. 3. Trevo EDFU. Fremont, CA: Stryker International; 2016. 4. Activase [prescribing information]. South San Francisco, CA: Genentech, Inc; 2018. *Mission: Lifeline Stroke provides timing recommendations based on the indications for use for mechanical thrombectomy devices. 2,3 Activase administration should occur as soon as possible but within 3 hours after symptom onset. 4 All routing decisions should conform to the regional stroke systems of care policy. 2 Patients suspected by EMS to have had a stroke but not an LVO should be taken to the nearest stroke center (ASRH, PSC, or CSC). 2

Case study: Mary, a 45-year-old Caucasian woman

Considerations when diagnosing acute ischemic stroke

Discussion question

Case study: Mary, a 45-year-old Caucasian woman

Discussion question

Is this a disabling stroke?

Determine patient eligibility for Activase (alteplase)

Activase (alteplase) Indication and Important Safety Information

Activase (alteplase) Important Safety Information (cont d)

Case study: Mary, a 45-year-old Caucasian woman

NINDS: A 2-part, randomized, double-blind trial of Activase (alteplase) vs placebo

Activase (alteplase) significantly reduced disability in patients with AIS

Activase (alteplase) safety outcomes when administered within 3 hours of symptom onset

Activase (alteplase): An integral part of AIS care

Case study: Mary, a 45-year-old Caucasian woman

Discussion question

Different imaging modalities have advantages and limitations 1,2

Case study: Mary, a 45-year-old Caucasian woman

Interfacility transport for patients receiving Activase (alteplase)

Case study: Mary, a 45-year-old Caucasian woman

Streamline the chain of stroke treatment DEEP D I V E Multiple parallel processes can help expedite treatment for patients with AIS who are eligible for Activase (alteplase) with or without subsequent mechanical thrombectomy 1 EXAMPLE OF A STROKE TREATMENT PATHWAY WITH PARALLEL PROCESSES 1-3 Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation. References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process of evaluating and stopping stroke. Presentation; 2016. 3. Activase [prescribing information]. South San Francisco, CA: Genentech, Inc; 2018.

Streamline the chain of stroke treatment (cont d) DEEP D I V E EXAMPLE OF A STROKE TREATMENT PATHWAY WITH PARALLEL PROCESSES 1-3 4 5 Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation. DTN=door-to-needle. References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Kalanithi L, et al. Stroke. 2014;45:3105-3111. 3. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process of evaluating and stopping stroke. Presentation; 2016. 4. Jauch EC, et al. Stroke. 2013;44:870-947. 5. American Heart Association/American Stroke Association. Target: Stroke Phase II Campaign Manual. Published October 2014. *Certain patient evaluations may be performed using telestroke services. 2

Streamline the chain of stroke treatment (cont d) DEEP D I V E EXAMPLE OF A STROKE TREATMENT PATHWAY WITH PARALLEL PROCESSES 1-4 5 6 Please see select Important Safety Information throughout and the full Prescribing Information available at this presentation. References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Kalanithi L, et al. Stroke 2014;45:3105-3111. 3. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process of evaluating and stopping stroke. Presentation; 2016. 4. Activase [prescribing information]. South San Francisco, CA: Genentech, Inc; 2018. 5. Jauch EC, et al. Stroke. 2013;44:870-947. 6. American Heart Association/American Stroke Association. Target: Stroke Phase II Campaign Manual. Published October 2014. 7. Powers WJ, et al. Stroke. 2015;46:3024-3039. *Certain patient evaluations may be performed using telestroke services. 3 In centers without capabilities to perform mechanical thrombectomy, patients should begin receiving Activase before being transferred for treatment at an experienced stroke center. 7

Summary

Appendix

Examples of imaging for AIS: CT

Examples of imaging for AIS: MR