7. Comprehensive Acute Stroke

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7. Comprehensive Acute Stroke
Comprehensive Acute Stroke Care in the
United States - organization and current trends
R A D O S L AV R AYC H E V, M D
D E PA R T M E N T S O F N E U R O L O G I C A L S U R G E R Y A N D N E U R O L O G Y
UNIVERSITY OF CALIFORNIA IRVINE SCHOOL OF MEDICINE
Acute Stroke Facts
 Leading cause of disability worldwide
 2nd leading cause of death worldwide
 >5 million stroke survivors
 $40 to $50 billion per year in the US
 90% of those who survive will have deficits
 80 % of strokes can be prevented
In a typical acute ischemic stroke, every
minute the brain loses
 1.9 million neurons
 14 billion synapses
 7.5 miles myelinated fibers
-- Saver, Stroke 2006
Patient
Knowledge
Calling
911
EMS
ED
Staff
Stroke
Team
Stroke
Unit
Stroke recognition and patient awareness
Patient Awareness:
IV TPA Under 3 Hours
Changes in Outcome Due to Treatment
Outcome
Nl/Near Normal
Improved
NNTB
8.3
3.1
For every 100 patients treated with tPA under 3 h, 32
benefit, 3 harmed
--Saver, Arch Neurol 2004; 61:1066-1070; Stroke 2007; 38:2279-2283
--AAN/ACEP/AHA Patient Educational Tool 2008
Stroke Diagnosis by EMS
LAPSS
Los Angeles Prehospital Stroke Screen
• Designed and validated by UCLA physicians
• Now part of paramedic training worldwide for
recognizing stroke in the field
UCLA Stroke Center
Currently Available Recanalization Therapies in Acute
Cerebral Ischemia
 Intravenous

IV TPA under 3 hours


FDA approved, guideline endorsed, RCT supported
IV TPA 3-.4.5 hours

RCT supported, guideline endorsed, under FDA review
 Catheter

Mechanical embolectomy ≤ 8 h (Stentrievers)


Mechanical aspiration ≤ 8 h (Penumbra device)


FDA approved for clot clearance, no RCTs
Mechanical angioplasty/stenting


FDA approved for clot clearance, no RCTs
FDA approved for failed medical therapy
IA fibrinolytics ≤ 6 h

Off label, 1.5 positive RCTs, weakly guideline endorsed
Catheter Intervention - For Large Vessel Occlusion
 Good outcome for patients with NIHSS > 20 in IMS
III Trial:


23.8% with Endovascular treatment
16.8% with IV TPA
> 3 hours
Ticking Clock
Tissue Clock
Tissue Status
Perfusion Status
Vessel Status
CBV CT
PCT
CTA
DWI
PWI
MRA
Hemodynamic
Compromise
Occlusions or
Stenoses
Multimodal CT
Multimodal
MRI
Bioenergetic
Compromise
Stroke Systems: Two Tier US Model
 EMS
--Trained dispatchers, high priority triage
--Paramedics trained in stroke recognition (e.g. LAPSS)
--Deliver patients to nearest stroke capable hospital
--Pre-arrival notification
 Primary Stroke Centers - Spokes
--Able to provide initial, acute care
--Able to use rt-PA and other acute therapies in a safe and efficient manner
--Can admit patients if they have a Stroke Unit
 Comprehensive Stroke Centers - Hubs
--Able to care for complex patients
--Advanced treatments (i.e. coils, stents, etc)
--Trained specialists in key areas (Vascular neurology, Neurointerventional
procedures, Neurocritical Care, Vascular Neurosurgery)
Brain Attack Coalition
 American Academy of Neurology
 American Association of Neurological Surgeons
 American Association of Neurosciences Nurses
 American College of Emergency Physicians
 American Heart Association
 American Society of Neuroradiology
 National Institute of Neurologic Disorders and Stroke
 National Stroke Association
 Neurocritical Care Society
 Stroke Belt Consortium
 Society of NeuroInterventional Surgery
 Veterans Administration
Supportive Data – Efficacy of Stroke Systems
 Stroke units (↓ LOS, ↓ complications)
 Stroke teams (more rapid responses)
 Neurological expertise (↓ mortality)
 Use of rt-PA
 Utility of QI/QA programs
 Care-Maps
• Circulation (2009)
• 790 US hospitals, 2003-2007
• 322,847 consecutive ischemic stroke and TIA patients
EMS Stroke Center Diversion to primary stroke center:
New York Experience
Door to stroke team (mins)
Door to CT
Door to TPA
IV TPA rate in TPA eligible
Pre
35
161
114
29%
6 wks
17
86
78
50%
Impact of Acute Ischemic Stroke Treatments
NNT
TPA 1-3h
Thrombectomy (lCA/M1) 5
TPA 3-4.5h
IA Lytics
Stroke Unit
Aspirin
3
6
7
10
77
Benefit per 100 pts
32
20
16
14
10
1
PRIMARY STROKE CENTER MAP
Multidisciplinary group; AAN, ACEP, AANS, AHA, NSA
AANN, NIH, ASNR, SBC – Stroke 2005
Comprehensive Stroke Centers:
Key Components
 Neurologists, neurosurgeons, ED personnel, and experts in






neuroendovascular procedures
Full intensive care unit
Neuroimaging interpreted within 20 minutes of acquisition
Neurosurgical personnel within 30 minutes
Door-to-needle time 60 minutes for IV tPA
Door-to-groin puncture time 90 minutes for IA
Availability of rehabilitation services
Pre Hospital Diversion to Comprehensive Stroke Centers:
Endorsed by AHA/ASA
UCI Stroke Center
Pre Hospital Acute Stroke Treatment
The Field Administration of Stroke Therapy –
Magnesium (FAST-MAG) Phase III Trial
NIH FAST-MAG Trial throughout LA and Orange
County
 Los Angeles and Orange Counties

Ethnically diverse population 13.3 million
 Prehospital



2298 paramedics
40 EMS Provider Agencies
315 ambulances
 Hospital


60 receiving hospitals
952 Physicians
 Sample

1700 Patients enrolled Jan 2005 – March 2013
Saver et al, International Stroke Conference 2014, San Diego, CA
FAST-MAG: Novel Aspects
 Diagnosis of Stroke in the field/ambulance


LAPSS
Physician Cellphone interview
 Rating Pretreatments Stroke Severity

LAMS
 Consent

Physician cell phone elicitation
 Randomization

Pre-encounter randomization
Saver et al, International Stroke Conference 2014, San Diego, CA
FAST-MAG: Results
 Specific Aim - Unsuccessful

No benefit of Magnesium
 System Aim – Successful

Field enrollment in phase 3 clinical trial is practical and feasible
 Fastest Delivery of Stroke Treatment in a Clinical Trial


74.3% of stroke patients treated in the first “golden hour”
75% of stroke patients treated in the first 20 min of ambulance arrival
 Pre-hospital EMS assessment with physician by cell phone

LAPSS – 97% accuracy
Saver et al, International Stroke Conference 2014, San Diego, CA
Video cellphone
Ambulance
Videocart
ED
Videorobot
Neuro ICU
Mobile Stroke Units – Future of AIS treatment
Prehospital Thrombolysis: A Manual from Berlin
 STEMO - A specialized ambulance equipped with:
 Mobile CT scanner
 Point of care laboratory
 Telemedicine
Ebinger et al, J Vis Exp 2013
Case Example
 60 y/o male with acute aphasia and R hemiplegia (NIHSS
22)
 Witnessed onset at work
 911 called
 EMS transported the patient to a primary stroke center
within 15 min (Riverside county)
UCI Stroke Center
Head CT – ASEPCTS score 9
UCI Stroke Center
Primary Stroke Center
 Patient was evaluated by teleneurology
 NIHSS 22 (global aphasia and R hemiplegia)
 Received IV TPA
 No improvement noted
Comprehensive Stroke Center
 Transferred to UCI Stroke Center via ambulance
 Arrived at UCI within 3.5 hours after onset
 Repeat exam showed persistent global aphasia and R
sided hemiplegia – NIHSS 22
UCI Stroke Center
Multimodal Imaging
UCI Stroke Center
 INR suite
 within 60 minutes of CT completion
UCI Stroke Center
Solitaire FR
UCI Stroke Center
UCI Stroke Center
Follow up
 Substantial improvement within 24 hours:
 Patient is moving the right side against gravity, comprehends
and utters simple words = NIHSS 10
UCI Stroke Center
Day 1
NIHSS 22
Day 5
NIHSS 5
UCI Stroke Center
60 y/o male with acute right sided weakness
and inability to speak
Last known well
911 call
Primary Stroke Center arrival
Teleneurology consult
IV TPA
@ 2hr
Comprehensive Stroke Center arrival
Multimodal Imaging
IA Recanalization
@ 7:00 AM
@ 10 min
@ 30 min
@ 1hr 05 min
@ 3hr 30 min
@ 3hr 50 min
@ 5hr 10 min
Acute Ischemic Stroke Care in the 21st Century
UCI Stroke Center
Symptoms
Multimodal Imaging
Call
Comprehensive Stroke Center
INR Suite
Imaging
Primary Stroke
Center
EMS
EMS
IV Lytic
IA Mechanical or Lytic
Angiogram
Stroke Unit
Telemedicine

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