Acute Stroke Treatment 2018 KPNC Stroke EXPRESS EXpediting the - - PowerPoint PPT Presentation

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Jeffrey G. Klingman, MD The Permanente Medical Group

Acute Stroke Treatment 2018 KPNC Stroke EXPRESS

EXpediting the PRocess of Evaluating & Stopping Stroke

Stroke Treatment in “the old days”

• Prior to 1996: back corner of

Emergency Department

1996: Revolution in Stroke Treatment : IV t-PA

• 1996-2011; IV alteplase (t-PA) < 3 hours

 Number Needed to Treat (NNT) = 4 to prevent major disability  Faster is better

2011: IV Alteplase to 4.5 hours

• 2011 IV Alteplase window expands to 4.5 hours

 No benefit beyond 4.5 hours

2013: Endovascular Stroke Treatment (EST) does NOT work

• 2013: 3 studies - no benefit to endovascular treatment vs IV

alteplase

N Engl J Med 2013

SYNTHESIS Endovascular therapy is not superior to standard treatment with intravenous t-PA. MR RESCUE Embolectomy was not superior to standard medical care in patients with either a favorable penumbral pattern or a nonpenumbral pattern IMS III Randomly assigned eligible patients who had received intravenous t-PA within 3 hours after symptom onset to receive additional endovascular therapy or ntravenous t-PA alone. The study was stopped early because of futility

2016: EST does work (in selected patients)

• 2016: 4 studies show benefit of

endovascular treatment in some stroke patients up to 6 hours

• Still time sensitive
• Many fewer patients qualify
• Difference from 2013 was patient

selection and devices

2018: The Window Extends : 6 to 24 hours

• 2018: DAWN and DEFUSE - 3: benefit to 6 -24 and 6- 16 hours in

highly selected Large Vessel Occlusion (LVO) patents

• NNT 2-3

DAWN DEFUSE 3

Hours 6-24 6-16 Rankin < 2 < 3 NIHSS > 9 > 5 CTA LVO in M1 or ACA LVO in M1 or ACA Core < 70ml on advanced imaging <70ml AND mismatch ratio of >1.8 AND penumbra of >15ml on advanced imaging

What would it take to…

• Achieve “world class” (15 - 20 minutes) door to needle

(DTN) times?

• Obtain very rapid CT angiogram (CTA) performance and

interpretation?

• Treat, evaluate, and transfer for endovascular therapy very

quickly

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Stroke EXPRESS: Key Components

• Alteplase

administered in CT suite

• Nearly all patients

receive a CTA

Rapid Transfer for EST

• If potential candidate

for EST, ambulance pre-ordered before CT/CTA completed

Early Stroke Neurologist Video Engagement

Direct to CT and CTA

• Rapid assessment
• Early alteplase
• rdering
• Processes

redesigned for maximal efficiency

• Stroke. 2018;49:133-139

Population evaluation by teleneurologist

Early Stroke Neurologist

Video Engagement

• Every patient is seen and evaluated on

arrival by teleneurologist

• Standardized searchable notes including
• Stroke alerts cancelled on arrival and

why

• Strokes treated and outcomes

including

• NIHSS exam
• Presence and location of LVO
• Transfers for EST

Results

Results

True or False? More patients are eligible for treatment with IV alteplase than are treated with endovascular therapy.

• A. True
• B. False

True False

0% 0%

IV alteplase

Endovascular Therapy

20

Response Counter

2546 patients eligible for acute stroke

treatment were identified and brought to us by paramedics.

Endovascular therapy is rare

18 acute strokes were evaluated to find 1 patient eligible for EST

Of these patients, 1241 (48.7%) had acute strokes.

• Of the acute strokes, 638 (25%) were

potential candidates for endovascular treatment (NIHSS >7) Of these, 141 patients (5.5% of total / 22% of high score) ended up actually having large vessel occlusion and received endovascular therapy.

600 Treated with IV Alteplase (4X as many as EST)

What about the extended window patients?

• Unknown number of patients will qualify for treatment
• Nobody has reported number screened for DAWN or DEFUSE 3
• EXTEND – IA found 70 candidates for treatment out of 549 patients

with LVO (13%)

• 1.7% of all stroke patients (45/2667) qualified for DAWN criteria in
• ne recent study
• Systems of care need to be prepared to screen potential

late window patients

• Last known well
• Baseline Rankin
• NIHSS > 5 (or >9)
• CT shows no bleed
• CTA shows occlusion
• CTP (or MRI) shows small core / perfusion mismatch

Endovascular Stroke Treatment

• Time is brain / faster is better
• EST is an infrequent, highly specialized treatment

 Many more patients need IV alteplase than EST (80%)  Not all centers should do EST  Like may procedural specialties experience and volume matters  Minimum 30 treatments per centers per year and 12 per doc per site  Rapid identification of EST, patient selection, and transfer is the key

Conclusions

• Acute stroke is a treatable condition
• Time is critical
• High functioning primary stroke centers are the key to

successful treatment

 Rapid clinical evaluation  Rapid IV alteplase  Rapid CTA  (Rapid CTP / MRI for late presenting patients)  Rapid transfer of selected patients to endovascular treatment centers

• High functioning Endovascular Stroke Treatment Centers

 Expedited patient acceptance  Adequate volume  Excellent treatment times and results