Complex Stroke Cases and Barriers in PSC and CSC

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1 Complex Stroke Cases and Barriers in PSC and CSC June 14, 2013 Wisconsin Coverdell Stroke Program Marc A. Lazzaro, MD Assistant Professor of Neurology and Neurosurgery Interventional and Vascular Neurology Froedtert and Medical College of Wisconsin

2 Disclosures No financial interest in any product or manufacturer mentioned herein.

3 Outline Stroke center designations Comprehensive Stroke Center Primary Stoke Center Acute Stroke Ready Hospital Advanced stroke therapy cases Triage, transport, and transfer planning Statewide Regional

4 Stroke center designations Acute Stroke Ready hospital (2015?) Serves rural population where large distance from PSC or CSC Designation not yet available Primary Stroke Center (PSC) 2003 Acute stroke team Emergency department Stroke unit Neurosurgical services Imaging, laboratory services Rehab services Stroke registry with outcomes Educational programs Comprehensive Stroke Center (CSC) 2012 PSC requirements and Volume criteria Aneurysm coiling/clipping IV tpa administration Catheter angiography and advanced imaging NICU with dedicated beds Peer review Stroke research Performance measures

5 What is certification? Certification recognizes centers that follow best practices for stroke care Driven by randomized data, guidelines, and consensus opinion Expectations include Standardized delivery of care Demonstrate compliance with clinical practice guidelines by the AHA/ASA or equivalent evidence-based guidelines. Performance measurement and improvement

6 Benefit of CSC

7 Benefit of CSC Meretoja et al. Study of effectiveness of PSCs and CSCs in Finland > 61,000 patients included Centers defined by most of criteria published by BAC Compared patients with 1 st time ischemic stroke admitted to PSC/CSC vs general hospital Triage largely determined by geography Meretoja A, et al. Stroke 2010; 41:

8 Benefit of CSC Meretoja et al. CSC/ PSC compared with the general hospitals CSC PSC 1 year case-fatality reduction 16% 11% Absolute reduction in death 2.4% 1.5% Absolute risk reduction of institutional care at 1 year 1% Meretoja A, et al. Stroke 2010; 41:

9 Outline Stroke center designations Comprehensive Stroke Center Primary Stoke Center Acute Stroke Ready Hospital Advanced stroke therapy cases Triage, transport, and transfer planning Statewide Regional

10 Acute Stroke Case #1 52 yo M h/o hyperlipidemia 2 weeks of severe coughing Presented with a left middle cerebral artery (MCA) stroke syndrome. NIHSS 19. Unknown onset. Last known well 4.5 hours.

11 Acute Stroke Case #1

12 Aneurysmal subarachnoid hemorrhage case 30 year old woman presented with worst headache of life and nausea. CT head showed diffuse subarachnoid hemorrhage

13 Aneurysmal subarachnoid hemorrhage case Catheter angiogram showed a right anterior choroidal artery aneurysm.

14 Outline Stroke center designations Comprehensive Stroke Center Primary Stoke Center Acute Stroke Ready Hospital Advanced stroke therapy cases Triage, transport, and transfer planning Statewide Regional

15 Wisconsin Stroke Centers Muliple Critical Access Hospitals -Future Acute Stroke Ready Hospitals? 2 Comprehensive Stroke Centers 29 Primary Stroke Centers

16 Ideal regional stroke system elements Patient-centered Organized Standardized Fast Non-duplication of services

17 Stroke system models Trauma model

18 Trauma centers Trauma centers (Level 1)

19 Trauma centers Trauma centers (Level 1,2,3) Stroke centers (CSC, PSC, ASR)

20 Trauma center transport times 45 minute transport zones to Level 1/2 (purple regions) Air or ambulance Base helipads indicated by stars

21 Trauma center transport times 60 minute transport zones to Level 1/2 (purple regions) Air or ambulance Base helipads indicated by stars

22 60 min stroke center access 60 minute transport zones (purple regions) to potential advanced stroke center locations Air or ambulance

23 60 min stroke center access Tertiary referral to Comprehensive Stroke Center Air transport

24 Regional Triage? Comprehensive stroke center Primary stroke center

25 45 min ground transport to CSC in Milwaukee

26 60 min ground transport to CSC in Milwaukee

27 Triage, transport, transfer (T3) Tools

28 Triage by severity and time

29 Triage dilemma Patients need to be treated FAST Severely affected patients may benefit from a CSC which may require longer transport.

30 Triage by severity and time Time remains the most important variable affecting response to treatment. Guidelines have promoted triage of stroke patients to the nearest Primary Stroke Center (PSC) This has resulted in an increase in delivery of IV tpa However, IV tpa does not work well with large blood vessel blockages Grotta JC. Stroke 2013; 44:

31 Early Recanalization The greatest benefit is achieved with EARLY IV tpa administration (early recanalization) Greatest benefit within 90 minutes 1 Strong correlation between recanalization and good functional outcome at 3 months when compared with non-recanalized patients. 2 Odds ratio 4.43 [95% CI, 3.32 to 5.91] 1. Hacke W et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-pa stroke trials. Lancet. 2004;363: Rha JH et al. The impact of recanalization on ischemic stroke outcome: a metaanalysis. Stroke 2007;38:

32 Optimizing revascularization Location of vessel occlusion is important Small vessel occlusions

33 Optimizing revascularization Location of vessel occlusion is important Medium and large vessel occlusions

34 Thrombolysis in small vessel disease A good outcome from IV thrombolysis is more common in stroke due to small vessel disease than other subtypes patients treated with IV tpa Stroke Subtype n Excellent outcome, mrs 0-1 Large artery atherosclerosis 217 (23%) OR 0.69 [CI ] Cardioembolic 389 (41%) OR 0.80 [CI ] Small vessel disease 101 (11%) OR 2.48 [CI ] Other 27 (2.8%) OR 0.32 [CI ] Undetermined 130 (14%) OR 1.85 [CI ] 1. Mustanoja, S et al. Outcome by stroke etiology in patients receiving thrombolytic treatment: Descriptive Subtype Analysis. Stroke. 2011;42:

35 Optimizing revascularization Distal vessel occlusions are more likely to recanalize with IV tpa than larger proximal vessels patients, median baseline NIH = 16, mean time to IV tpa = 145 +/- 68 minutes Location OR for complete recanalization Number of patients Distal MCA 2 50 of 113 (44.2%) Proximal MCA of 163 (30%) Terminal ICA of 17 (5.9%) Tandem cervical ICA and MCA of 22 (27%) Basilar of 10 (30%) 1. Saqqur, M et al. Site of arterial occlusion identified by TCD predicts response to IV thrombolysis for stroke. Stroke. 2007; 38:

36 Time-Location Based Recanalization Large Vessel Clot Location Small Vessel ENDOVASCULAR THERAPY IV tpa IA -tpa MECHANICAL THROMBECTOMY Hours

37 Optimizing revascularization Ischemic stroke < 4.5 hours CT negative for bleed Disabling deficit Fullfills inclusion / exclusion criteria IV tpa > 4.5 hours or unknown onset Elevated INR Recent surgery other contraindications Medium or large vessel occlusion Clinical Non-responders Potential candidates for endovascular therapy

38 Endovascular therapies for acute ischemic stroke Intra-arterial tpa Several randomized trials and case series have led to endorsement by multiple organizations American Heart Association recommendation for endovascular stroke therapy: 1 Class I, Level of evidence B recommendation for IA thrombolysis in select patients under 6 hours from symptom onset due to MCA occlusion Class II, Level of evidence B recommendation for mechanical thrombus extraction 1. Meyers, PM et al. Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures. Circulation. 2009;119:

39 Stroke triage Patients with severe stroke syndromes suggestive of a large artery blockage may benefit from the longer transit time to a CSC These centers may be able to offer more comprehensive therapies for these complex stroke patients Endovascular clot removal Hemicraniectomy NICU care Grotta JC. Stroke 2013; 44:

40 Triage by severity and time Grotta JC. Stroke 2013; 44:

41 Tiered regional EMS triage

42 Tiered regional EMS triage Tier One: Mild stroke symptoms LAMS score 1-2 Triage to highest center within 20 minutes Likely needs IV tpa, less likely needs more aggressive therapy 45 minute ground transport region marked in green

43 Tiered regional EMS triage Tier Two: Moderate to severe stroke symptoms LAMS score 3-5, or drowsy, or impaired consciousness Triage directly to comprehensive stroke center 45 minute ground transport region marked in green

44 Adjunctive support from CSC Telestroke communications Assist with tpa administration decisions Triage patients to stay at local site or transfer for more aggressive therapy 45 minute ground transport region marked in green

45 Adjunctive support from CSC Transfer Ability to receive inter-hospital transfers of complex stroke patients or those who have worsened. 45 minute ground transport region marked in green

46 Thank you for your attention Marc Lazzaro, MD

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