Acute Ischemic Stroke in the Emergency Department Robert L. - - PDF document
10/4/18 Acute Ischemic Stroke in the Emergency Department Robert L. Alunday, MD Assistant Professor Departments of Neurosurgery and Emergency Medicine Medical Director, Neurosciences ICU University of New Mexico No financial disclosures 1
10/4/18 1
Robert L. Alunday, MD Assistant Professor Departments of Neurosurgery and Emergency Medicine Medical Director, Neurosciences ICU University of New Mexico
10/4/18 2
10/4/18 3
795,000 Annually 1 every 40 seconds Stroke kills every 4 minutes $34 billion each year
https://www.cdc.gov/stroke/facts.htm
Case courtesy of Dr Frank Gaillard, radiopaedia.org
Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 22770
https://sites.google.com/a/wisc.edu/neuroradiology/image- acquisition/vascular-imaging/mr-angiography
10/4/18 4
SBP<140, until secured
BP control? Surgery Minimally invasive surgery
10/4/18 5
Hanley Lancet Neurol. 2016 November ; 15(12): 1228–1237
10/4/18 6
https://www.ev3.net/assets/007/5793.jpg
http://resusreview.com/wp- content/uploads/2013/05/Alteplase_Mixing_Procedur e_9.jpg
10/4/18 7
There is a difference between Infarction and Ischemia You can’t help infarcted brain
10/4/18 8
10/4/18 9
https://med.stanford.edu/neurology/divisions/stroke/research1.html
Wardlaw et al. Cochrane Database (review) 2014
10/4/18 10
Pooled analysis of 3670 pts from ECASS I, II, III, ATLANTIS, NINDS, and EPITHET trials
Lees et al. Lancet 2010; 375:1695-1703
Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke. 2016 Feb;47(2):581-641
10/4/18 11
Diagnosis of ischemic stroke causing measurable neurological deficit Onset of symptoms <3 h before treatment begins Age ≥18 y
Significant head trauma or prior stroke in the previous 3 mo Symptoms suggest SAH Arterial puncture at noncompressible site in previous 7 d History of previous intracranial hemorrhage Intracranial neoplasm, AVM, or aneurysm Recent intracranial or intraspinal surgery Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis, including but not limited to Platelet count <100 000/mm3 Heparin received within 48 h resulting in abnormally elevated aPTT above the upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 s Current use of DOAC’s with elevated sensitive laboratory tests (eg, aPTT, INR, platelet count, ECT, TT, or appropriate factor Xa activity assays) Blood glucose concentration <50 mg/dL (2.7 mmol/L) CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) Relative exclusion criteria
10/4/18 12
Only minor or rapidly improving stroke symptoms (clearing spontaneously) Pregnancy Seizure at onset with postictal residual neurological impairments Major surgery or serious trauma within previous 14 d Recent gastrointestinal or urinary tract hemorrhage (within previous 21 d) Recent acute myocardial infarction (within previous 3 mo)
Current intracranial hemorrhage Subarachnoid hemorrhage Active internal bleeding Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma Presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms) Bleeding diathesis Current severe uncontrolled hypertension.
10/4/18 13
n NIHSS for inclusion NIHSS Median (IQR) time from Stroke onset Additional Imaging time to groin puncture (min) Median (IQR) IV-tPA use
MR CLEAN
500 >1
17 (14-21) 6 hours
CTA
260 (210- 313) not required
ESCAPE
316 >6
16 (13-20) 12 hours
multiphasic CTA
185 (116- 315) not required
EXTEND- IA
70
none 17 (13-20) 6 hours
CTA and CTP
210 (166- 251) required
SWIFT PRIME
196 8-29
17 (13-20) 6 hours
CTA/PCT
184 required
REVASCAT
206 >6
17 (12-19) 8 hours
CTA
269 (201- 340) not required
10/4/18 14
MORTALITY mRS %mRS 0-2 TICI 2b/3 symptomatic ICH MR CLEAN
18.9% / 18.4% at 30 days
3 / 4
33% / 19%
58.7%
7.7% / 6.4% ESCAPE 10% / 19%
2 / 4
53% / 23%
72.4%
3.6% / 2.7% EXTEND IA 9% / 20%
1 / 3
70% / 40%
86%
0% / 6% SWIFT PRIME 9% / 12%
2 / 3
60.1% / 35.5%
88%
5.1% / 7.2% REVASCAT 18.4%/15.5% at 90 days 43.7% / 28.2%
65.7
4.9% / 1.9%
Imaging base evidence of large vessel occlusion Imaging-based exclusion of patients with a large core Newer and better device (TICI 2b/3 of 25%-41% on early generation IAT vs 59-88% with stent retriever)
10/4/18 15
NNT to reduce mRS by 1 point: 2.6 NNT to get to mRS 0-2: 6 NNT for PCI for STEMI to prevent long term death: 29
Lancet 2016; 387: 1723–31
10/4/18 16
New stroke symptoms beginning within: 6 hours (anterior circulation, ICA, MCA) 12 hours (posterior circulation, basilar artery) Pre-stroke modified Rankin Scale 0 – 3 NIH Stroke Scale Score 6 or higher CT head with NO evidence of hemorrhage ASPECT score 6 – 10 CTA with occlusion of ICA or MCA (horizontal segment or proximal first vertical segment) or basilar artery that correlates with new stroke symptoms
10/4/18 17
Published Nov 11, 2017
206 patients enrolled (planned for 500) Multicenter, prospective, RCT, Bayesian adaptive-enrichment design, and blinded assessment of endpoints Industry sponsored Authors had unrestricted access to the data analysis was performed by data-management staff from Styker, with
10/4/18 18
LVO present Age >80, NIHSS >10, Infarct <21ml Age <80, NIHSS >10, Infarct 21-31ml Age <80, NIHSS >20, Infarct 31-51ml
10/4/18 19
10/4/18 20
Published Jan 24, 2018
If NCCT done, ASPECT score >6 Infarct core <70ml Ratio of ischemia to infarction of 1.8 Absolute volume of penumbra of 15ml
10/4/18 21
Sponsored by the NIH Any FDA thrombectomy device was used
10/4/18 22
Enrolled 182/476 patients, but stopped early in light of DAWN trial results (Per NIH)
10/4/18 23
10/4/18 24
You can help some patients in the 6-24 hour window Advanced imaging necessary
New stroke symptoms beginning within 6 – 24 hours (anterior circulation = ICA or MCA only; Does not include basilar artery) Pre-stroke modified Rankin Scale 0 – 3 CT head with NO evidence of hemorrhage MRA or CTA with occlusion of ICA or MCA (horizontal segment or proximal first vertical segment) Infarct core on DWI or CBV less than 70 ml Ratio of 1.8 of ischemic tissue to infarcted tissue (perfusion mismatch) Tmax greater than 6 seconds/ADC i. ADC less than 620 Tmax greater than 6 seconds /CBV Only if CBV is less than 30%
10/4/18 25
10/4/18 26
10/4/18 27
10/4/18 28
N Engl J Med 2018; 379:611-622
503 patients enrolled Alteplase vs standard care 70 centers in 8 European countries Last Known well >4.5 hours to infinity, but symptom recognition within 4.5 hours Early stroke based on MRI (DWI+ and FLAIR-)
10/4/18 29
10/4/18 30
TIME IS BRAIN Alteplase is given more often than FDA indicates Advanced imaging is becoming critical Team approach (nursing, EM, stroke neurologists, radiology, pharmacy) is the only way to diagnose and treat timely