Developing and applying stroke systems of care Andrew M. Demchuk MD - - PowerPoint PPT Presentation

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Developing and applying stroke systems of care Andrew M. Demchuk MD - - PowerPoint PPT Presentation

May 10, 2023 495 likes •1.29k views

Developing and applying stroke systems of care Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Deputy Department Head, Dept Clinical Neurosciences HSF Chair in Stroke Research Professor, Depts of Clinical Neurosciences and

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Developing and applying stroke systems of care

Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Deputy Department Head, Dept Clinical Neurosciences HSF Chair in Stroke Research Professor, Depts of Clinical Neurosciences and Radiology Cumming School of Medicine University of Calgary

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Disclosure Slide

  • I have not received an honorarium from Hoffman LaRoche

(licensure of tPA) but have received honorarium from Medtronic (supplier of SOLITAIRE FR stentriever) for CME events

  • No stocks or direct investments with pharmaceutical or device

companies involved in stroke

  • Co-founder/shareholder Quikflo Health start-up (acute stroke

software)

  • Several clinical trial responsibilities:
  • IMS-3- Exec committee, CT core lab PI
  • ESCAPE- Neuro-PI
  • REVASCAT- CT core lab co-PI
  • CLOTBUST-ER – CTA substudy PI
  • ARTSS-2 – CTA substudy core lab PI
  • ENCHANTED – International Advisory Committee
  • PRACTICE- DMC chair
  • DEFUSE 3- Safety monitor
  • ANNEXA-4 – Adjudication committee
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3

Stroke Care Continuum

Stroke Onset EMS Transport ED Time Stroke Team Assessment Imaging Acute Treatment Admission

Clinical Worsening/ Complication Prevention

Rehabilitation Reintegration Secondary Prevention Primary Prevention

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Treatments for Complication Prevention

Stroke units ASA

CT scan Hemicraniectomy

1970 1980 1990 1995 2000 2002 2004 2010 2013 2015

Above knee pneumatic compression stockings Early enteral feeding good

No Early BP lowering

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Per million population

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Reperfusion Treatment Advances

tPA<3h

CT scan tPA 3-4.5h tPA for elderly

1970 1980 1990 1995 2000 2002 2004 2008 2011 2013 2015

Endovascular tx

Thrombectomy

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Two Decades Behind But Finally an Impactful Treatment

2016 1976

2016

Goyal et al Mechanical Thrombectomy***

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Intravenous rtPA Balance between benefit and risk

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Large clot Proximal artery Severe deficits

10

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SolitaireTM FR TREVO

Thrombectomy: Stent retrieval devices

Thrombus in the stent and aspirate

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10 20 30 40 50 60 70 80 90

Series 3

Series 3

TICI 2b- 3

Stent Retrieval Devices: High Reperfusion Rates

Stroke 2004 1 ; Stroke 2007 2; NEJM 2013 3,4; Lancet 2012 5; Lancet 20126 ; ISC 20127 ; Stroke 20128; ISC 20139

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14 Independence Dependence

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15

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Shifting the Paradigm in Alberta

Stroke Care in the 21st Century

ESCAPE Inclusion criteria

  • Acute ischemic

stroke (NIHSS > 5)

  • 12 hour window
  • No upper age limit
  • Good functional

status

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The 3-5 minute CT/CTA protocol

EIC- ASPECTS Small core >6 Occlusion site M1+/-ICA “Collaterals” good/mod

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Overall Results

2016-03-21 www.escapetrial.org 18

29.3% 53.0%

RR: 1.8 (1.4-2.4) NNT = 4.2 [1/0.237]

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Overall Results

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cOR: 2.6 (1.7-3.8) NNT ~3

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Safety Outcomes

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Intervention [n=165] Control

[n=150]

RR (CI95) Adjusted§ RR (CI95)

Death [N=311] 10.4% 19.0% 0.5 (0.3-0.95) 0.5 (0.3-0.8) Large/malignant MCA stroke 4.9% 10.7% 0.5 (0.2-1.0) 0.3 (0.1-0.7) sICH (clinically determined

at site)

3.6% 2.7% 1.4 (0.4-4.7) 1.2 (0.3-4.6) Access site hematoma 1.8% 0%

  • MCA perforation

0.6% 0%

  • 6%
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Endovascular thrombectomy after large-vessel ischemic stroke: a meta-analysis of individual patient data from five randomised trials HERMES Collaborators

Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke trials (HERMES)

2016-03-21 HERMES Collaboration 21

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Overall Treatment Effect

2016-03-21 HERMES Collaboration 22

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Overall Treatment Effect NNT = 2.6

2016-03-21 HERMES Collaboration 23

25.5% 46%

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Benefit even if not tPA eligible

2016-03-21 HERMES Collaboration 24

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Patients much improved the next day

2016-03-21 HERMES Collaboration 25

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No increased bleeding Reduction in Mortality trend

2016-03-21 HERMES Collaboration 26

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Treatment effect by age mRS 0-2 at 90 days

2016-03-21 HERMES Collaboration 27

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Effect size by NIHSS

2016-03-21 HERMES Collaboration 28

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Treatment effect is strongest if carotid occlusion (pint=0.17)

2016-03-21 HERMES Collaboration

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Treatment effect is strong if cervical ICA too (pint=0.17)

2016-03-21 HERMES Collaboration

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Onset to Substantial Reperfusion and Disability Outcomes (mRS) at 3 Months

2016-03-21 HERMES Collaboration 31

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Onset to Randomization and Disability Outcomes (mRS) at 3 Months

2016-03-21 HERMES Collaboration 32

3-5% absolute decrease in good outcome per hour 1-2% absolute increase in mortality per hour

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~1 in 4 or 5 strokes = EVT accessible occlusion 100-150 endo eligible/1 million/yr

What is the potential for EVT?

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During this Morning Somewhere in Western Canada…. At least one individual has suffered a major ischemic stroke that is very suitable for endovascular rescue if….

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Endovascular Treatment How Do We Build The System of Care To Do This?

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~40 PCI Facilities in Canada

for Acute Myocardial Infarction

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Is Your Region Equipped with Stroke Thrombectomy Facilities Nearby?

Are there neurointerventionalists available 24h/365d at these facilities?

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The How To?

  • EMS transport to right hospital
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How are ambulances routing hyperacute major deficit patients?

PSC CSC PSC PSC EMS transport to any hospital should be unacceptable!

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Centralize care: Redirect ambulance to stroke centre

PSC CSC PSC PSC

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US Model of Hubs and Spoke Model

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“Time is Brain”

Primary Stroke Centre (PSC) Criteria: CT scan availability Door to CT time less than 20 minutes with pre-alert Stroke expertise on-site or available by Telestroke link rtPA treatment availability Serves all surrounding communities in which it is the nearest PSC Comprehensive Stroke Centre (CSC) Criteria: CT scan availability Door to CT time less than 20 minutes with pre-alert Stroke team on-site Neurosurgical expertise on-site Neuro-interventionist expertise on-site Central hub of stroke neurologist expertise in a telestroke network

Stroke Centre Designation Criteria

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Alberta Acute Stroke Treatment 2016

Comprehensive Stroke Centre Primary Stroke Centre

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Transport decisions evolving

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Transport decisions evolving

angio EVT

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The How To?

  • EMS transport to right hospital
  • Primary Stroke Centres
  • CT/CTA 24/7
  • Telestroke capability to hub CSC
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Mechanical thrombectomy Ideal If

M1 MCA Occlusion Carotid Occlusion

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NCCT/CTA now standard of care and should be performed sequentially while on CT table

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“Neurons over nephrons” in major stroke

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“CIN” called into question

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Primary Stroke Centre Model with Telestroke

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The How To?

  • EMS transport to right hospital
  • Primary Stroke Centres
  • CT/CTA 24/7
  • Telestroke capability to hub CSC
  • DTN<30 min
  • DIDO <45 min
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Target: Stroke Best Practice Strategies

  • 1. *EMS Pre-Notification
  • 2. Stroke Toolkit
  • 3. Rapid Triage and

Stroke Team Notification

  • 4. *Single Call Activation

System

  • 5. *Transfer Directly to CT
  • 6. Rapid Brain Imaging
  • 7. *POC Laboratory

Testing

  • 8. *Premix TPA
  • 9. *Rapid TPA Access -

store TPA in ED/radiology, start in imaging suite 10.Team approach 11.*Prompt data feedback

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STAT! STROKE Prehospital Notification

Stroke neurologist Triage nurse ED physician CT tech Patient care attendant ED bedside nurse Angio team Neuro-IR

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SLIDE 57 Phase 2 Phase 1 Phase 2 Phase 3

NCCT CTA

Keep on the CT table for immediate CTA!

NCCT prep/scanning time <5 min

CTA

NCCT to tPA decision via telestroke <10 min mix/prep for bolus <5 min Door to CT scanner <10 min CTA prep/scanning time <5 min CTA reformatting time <5 min All images to decision <10 min

DTN <30 min/ DIDO <45 min

Decision to door out <10 min

Keep on EMS stretcher!

Door in door out <45 minutes Door to needle <30 minutes

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LSN Time EMS Activation First door in CT/CTA IV tPA start time First Door Out Second door in Repeat CT/CTA Groin Puncture

Revasculariz

  • ation

Second door

  • ut

Home time % in first 90 days

FUTURE

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The How To?

  • EMS transport to right hospital
  • Primary Stroke Centres
  • CT/CTA 24/7
  • Telestroke capability to hub CSC
  • DTN<30 min
  • DIDO <45 min
  • Comprehensive Stroke Centre
  • Bypass of PSCs if severe+by distance
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Onset to Substantial Reperfusion and Disability Outcomes (mRS) at 3 Months

2016-03-21 HERMES Collaboration 60

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61

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Transport decisions evolving

angio EVT

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Transport decisions evolving

angio EVT

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Transport decisions evolving

angio EVT

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What to do when more than one stroke centre in metro area?

PSC CSC PSC PSC

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Golden 2 Hours of Stroke

2016-03-21 HERMES Collaboration 66

P=0.001

66.9% 8.3%

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2016-03-21 HERMES Collaboration 67

207 65 15 21 29 50 31 32 47 42 Transfer Direct admit

Workflow Times in Direct and Transfer Patients

(minutes, medians) Onset to ED ED to imaging start Imaging to randomization Randomization to puncture Puncture to reperfusion

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Baseline Characteristics Differed by Time Window of Randomization

30-120 mins 121-240 mins 241-360 mins >360 mins N 194 657 352 79 Age 68.7 66.5 65.8 64.5 Sex (female) 53.1% 46.0% 44.7% 53.2% NIHSS 17.2 17.0 16.5 16.1 Direct (vs transfer) 97.9% 75.5% 37.8% 66.7% IV tPA 85.6% 89.0% 86.9% 45.6% Location ICA 32.1% 21.8% 16.2% 21.8% M1 62.2% 70.2% 76.2% 71.8% ASPECTS 9.0 8.4 7.8 8.0 2016-03-21 HERMES Collaboration 68

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Alberta Acute Stroke Treatment 2016

Comprehensive Stroke Centre Primary Stroke Centre

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3 way onscene communication for rural areas

  • LAMSS >4 + <6h/wakeups
  • EMS provider at scene
  • Comprehensive stroke centre team
  • Transport physician
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The Conversation at Scene

Truly Hemiplegic? Helicopter available? Weather? Transport times to PSC vs CSC? Last seen normal? tPA ineligible? Clinically worsening? ICH? Premorbid status? Should ambulance rendezvous with helicopter? PSC operational?

DECISION! GO!

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Optimize NCCT mCTA with thick MIPs Pr

CTA 23 mm Thick MIPs

1223h

mCTA CTA neck/head Thin section NCCT Quality NCCT

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mCTA with thick MIPs Protocol

1223h

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Fast DTNs translate to fast DTGP times

Median DtoGP: 60 66 60 62 47 25th% DtoGP: 44 42 46 35 30

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Thank-you for your attention!