Acute Stroke Interventions: Indications, Access, & Outcomes - - PDF document

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Acute Stroke Interventions: Indications, Access, & Outcomes - - PDF document

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4/4/2019 Acute Stroke Interventions: Indications, Access, & Outcomes Daniel Cooke Assc. Prof. Dept. of Radiology UCSF Director NIR ZSFG UCSF Vascular Symposium Thursday, April 4 3:45-4:05pm 1 Disclosures None 2 1 4/4/2019 The

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Acute Stroke Interventions: Indications, Access, & Outcomes

Daniel Cooke

  • Assc. Prof. Dept. of Radiology UCSF

Director NIR ZSFG UCSF Vascular Symposium Thursday, April 4 3:45-4:05pm

Disclosures

  • None

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The Message

  • Time is brain.

– The interval from symptom onset to

reperfusion is the most significant modifiable variable in predicting clinical

  • utcome.

Outline

  • Background
  • Evidence

– Time – Physiology

  • Workflow

– Direct-to-Angio – Anesthesia – Access

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AIS

  • Epidemiology

– 800K/year US

  • 5th leading cause mortality
  • Leading cause morbidity
  • Natural History Large Vessel Occlusion

– ~15% of all ischemic stroke – Resistant to IV r-tPA with low rates of early recanalization

  • distal ICA 4.4%,
  • M1MCA 32.3%,
  • M2-MCA 30.8%,
  • basilar 4%

Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, Watson T, Goyal M, Demchuk AM. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010 Oct;41(10):2254-8

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CT ASPECTS

http://www.aspectsinstroke.com

Trials Summary

Grotta J and Hacke W. Stroke Neurologists Perspective on the New Endovascular Trials. Stroke June 2015.

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Time

Grotta J and Hacke W. Stroke Neurologists Perspective on the New Endovascular Trials. Stroke June 2015.

“drip and ship”

HERMES

The Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration 19 20

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HERMES

  • Pooled patient data from 5 RCTs

– 1287 patients – Pre-specified outcomes

  • Sub group analysis

Saver JL, et al ; HERMES Collaborators.. Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis.

  • JAMA. 2016 Sep 27;316(12):1279-88.

Goyal M, et al.. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.

  • Lancet. 2016 Apr 23;387(10029):1723-31

HERMES

  • 2.6 NNTT for 1

point mRS improvement at 90 days

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HERMES HERMES

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Time

  • 6% decrease in

absolute risk difference in good

  • utcome (mRS < 3)

for every hour delay in reperfusion

AHA/ASA 2015 Guidelines

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Physiology

  • Beyond 6 hours
  • Unknown LSN

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Time vs. Physiology

  • DAWN (n = 206)

– Intervention vs. Medical 6 – 24 hours LSN

  • Stopped early (2.28.17)

– 90 day mRS < 3: 48.6% vs. 13.1%

  • NNT 2.8

Nogueira RG, et al. DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018 Jan 4;378(1):11-21c

Time vs. Physiology

  • DEFUSE 3 (n = 182)

– Intervention vs. Medical 6 – 16 hours LSN – < 70 ml (core) AND > 1.8 penumbra:core – 90 day mRS < 3: 41% vs. 11.5%

Albers GW et al. DEFUSE 3 Investigators. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018 Jan 24

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AHA/ASA 2018 Guidelines AHA/ASA 2018 Guidelines

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Beyond RCTs

  • Core infarct (CBF): “too sick”

Campbell et al. The Lancet Neurology, 2019

Beyond RCTs

  • Core infarct (CBF): “too sick”

Campbell et al. The Lancet Neurology, 2019

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Beyond RCTs

  • Clinical presentation (NIHSS < 6): “too well”

– Sarraj et al.

  • 90 MM vs. 124 EVT
  • 67% vs. 63% mRS 0-2 @ 90 days
  • 0% vs. 6% SICH

Sarraj et al. Stroke, 2018

WORKFLOW: MAKING TIME

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Workflow

Bourcier et al. JAMA Neurology. 2019

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Workflow

  • Direct-to-angio

– Psychogios et al.

  • 44 (MDCT) vs. 30 patients (FPCT)
  • 22/30 with AIS
  • 54.5 min vs. 20.5 min

PsychogiosMN, Behme D, Schregel K, Tsogkas I, Maier IL, Leyhe JR, Zapf A, Tran J, Bähr M, Liman J, Knauth M. One-Stop Management of Acute Stroke Patients: Minimizing Door-to-Reperfusion Times. Stroke. 2017 Nov;48(11):3152-3155

Workflow

  • Direct-to-angio

– Mendez et al.

  • 145 (MDCT) vs. 97 (FPCT)
  • 79/97 with LVO AIS
  • 70 min vs. 16 min

Mendez et al. Stroke. 2018

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Workflow

  • Direct-to-angio

Mendez et al. Stroke. 2018

Workflow

  • Anesthesia

– Campbell et al. (Lancet Neuro., 2018)

  • Meta analysis 797 patients (236 GA)
  • 50% vs. 40% mRS < 3 at 90 days (p = 0.008)

Campbell BCV et al HERMES collaborators. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol. 2018 Jan;17(1):47-53

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Workflow

  • Access

– Femoral – Radial – Carotid

Workflow

  • Access

– Chen et al. (n = 18)

  • Radial access
  • No difference in puncture-to-reperfusion times (~ 60

min) relative to femoral access.

  • Similar TICI, pass number, and mRS

Chen et al. JNIS. 2019

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Mokin et al. JNIS. 2013

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Workflow

  • Access

– Fjetland et al. (n = 7)

  • Carotid access
  • Access to reperfusion time 45 min. (mean)
  • 1 hematoma requiring surgery (manual compression for

all others).

  • 100% TICI2b or 3

Fjetland et al. JVIR. 2018

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Conclusion

  • Standard of care
  • Time is brain

– Minutes matter – Code Culture

UCSF/ZSFG are the Stroke Centers for the Bay Area

Thank you

Questions? Daniel.cooke@ucsf.edu

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Mission Protocol

  • Who’s eligible: +Cincinnati Prehospital Stroke

Scale and Last Known Normal < 6 hours → ambulance notifies ZSFG

  • ZSFG RN asks for primary language, anticoagulant

use, placement of 18g IV

  • EMS obtains vitals, IV, fingerstick glucose
  • Patient arrives at Mission Drop-off (hallway at

ambulance entrance across from CT 1)

  • Welcoming committee: ED RN, MEA, ED resident

and attending

Mission Protocol

  • Neurology resident joins team
  • ED RN draws labs off existing IV, does

assessment, places transport monitor, removes metal jewelry

  • ED resident does rapid assessment: ABCs,

FAST-ED plus threat score, focused exam to determine: stable CVA, unstable CVA, not CVA

  • If stable CVA: to CT on EMS gurney, weigh in
  • n way in

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Mission Protocol

  • IV-tPA given while on CT table
  • If 2nd line not established, placed on CT table
  • CT angiogram and perfusion
  • If large vessel occlusion: direct to NIR Suite

Mission Protocol

  • Launched July 2017
  • Stroke metrics through 9/30/18:

– Door-to-CT: 13 minutes (mean), 8 minutes (median) – Door-to-tPA (n=90): 40 minutes (mean), 34 minutes (median) – Door-to-embolectomy (groin puncture) (n=43): 99 minutes (mean), 94 minutes (median)

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Goal of Ischemic Stroke Treatment

Before Intervention After Successful Intervention

Images courtesy of Dr. Joey English – Used with

  • Permission. Results from

case studies are not predictive of results in other

  • cases. Results in other cases

may vary.

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Workflow

  • Anesthesia

– Henden et al. (Stroke., 2017)

  • AnStroke RCT 90 patients
  • 42% vs. 40% mRS < 3 at 90 days (p = 1)

Löwhagen Hendén P, Rentzos A, Karlsson JE, Rosengren L, Leiram B, Sundeman H, Dunker D, Schnabel K, Wikholm G, Hellström M, Ricksten SE. General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke).

  • Stroke. 2017 Jun;48(6):1601-1607

Workflow

  • Anesthesia

– Simonsen et al. (JAMA Neuro., 2018)

  • GOLIATH RCT 128

patients

  • OR 1.9 mRS < 3 at 90

days

Simonsen CZ, Yoo AJ, Sørensen LH, Juul N, Johnsen SP, Andersen G, Rasmussen M.Effect of General Anesthesia and Conscious Sedation During Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2018 Jan 16

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HERMES AHA 2018

  • “It is reasonable to select an anesthetic

technique during endovascular therapy for AIS

  • n the basis of individualized assessment of

patient risk factors, technical performance of the procedure, and other clinical

  • characteristics. Further randomized trial data

are needed.” COR, LOE (IIa, B-R)

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