Advances in Stroke Care - ogdensurgical.com · Case Presentation • Acute Ischemic Stroke Treatment Updates ... • Stroke is the #1 cause of disability • Approximately 795,000

Comprehensive Stroke Center at Intermountain Medical Center

Megan Donohue, MDVascular Neurologist

Medical Director of Stroke Program

Advances in Stroke Care

Overview

• Stroke Statistics and Subtypes• Case Presentation• Acute Ischemic Stroke Treatment Updates• Comprehensive Stroke Center• Summary

Stroke Statistics

• Stroke is the 5th cause of death in the United States• Stroke is the #1 cause of disability• Approximately 795,000 strokes occur each year • Every 40 seconds someone has a stroke in USA• Every 3 minutes 42 seconds someone dies of a stroke• Stroke accounts for 1 of every 19 deaths in the USA

Stroke Statistics • 7 million Americans > 20 years of age report having had a stroke• From 1995- 2011 Stroke hospitalization rates doubled for males 18-44• Approximately 90% of stroke risk is attributable to modifiable risk factors

(HTN, obesity, HLD, hyperglycemia, renal dysfunction)• 74% attributed to behavioral risk factors (smoking, sedentary lifestyle, diet)• 29% attributed to air pollution globally

Normal IschemicStroke87%

IntracerebralHemorrhage

10%

SubarachnoidHemorrhage

3%

Stroke Subtypes

Presenter

Presentation Notes

There are 3 different types of stroke with different causes, risk factors workup , and different outcomes/survival .

Case47 yo man stumbled out of his house 6AM for his coworker to pick him up

for work. All he could say once getting into the car was “Holy Cow”. Friend thought he was acting strange, not talking much. Thought it was

related to being early in the morning.

When arrived at work, he wasn’t able to get out of car, coworker drove straight to ED.

Initial history challenging, last known well (LKW) unclear

12111104040232123

• IV Thrombolytics• Endovascular Therapy (Thrombectomy)

Acute Stroke Treatment Eligibility

Acute Stroke Treatment

NINDS

0-3 h TPA1995

2008

ECASSIII3-4.5 h

TPA

6 RCTs

0-6 h EVT2015

2017/18

DAWNDEFUSE3

6-18/24h EVT

EXTEND

4.5-9 h TPA2019

NNT = 7

17.320.5

ICH = 6.4%ICH = 0.6%

Lancet 2004; 363: 768–74

NNT=14

52.4

45.1

Acute Stroke Treatment: 2015

Goyal M., Menon B. K., van Zwam W. H., et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet. 2016;387(10029):1723–1731. PMID 26898852.

(Includes MR CLEAN, REVASCAT, SWIFT-PRIME, EXTEND-IA, ESCAPE)

2017-2018 Extended Endovascular windows

Figure: Composite disability scores from the DEFUSE 3 and DAWN trials on the modified rankin scale at 90 days. Blocks within dashed line are more disabled. Data derived from the DEFUSE 3 trial (reference above) and the DAWN trial (Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, BudzikRF, Bhuva P, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine. 2018). (AHA Blog, Extension of Therapeutic Time Window for Acute Ischemic Stroke and its Implications —Highlighting the DEFUSE 3 Trial)

DEFUSE 3 and DAWN Trials

Figure: Composite disability scores from the DEFUSE 3 and DAWN trials on the modified rankin scale at 90 days. Blocks within dashed line are more disabled. Data derived from the DEFUSE 3 trial (reference above) and the DAWN trial (Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, BudzikRF, Bhuva P, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine. 2018). (AHA Blog, Extension of Therapeutic Time Window for Acute Ischemic Stroke and its Implications —Highlighting the DEFUSE 3 Trial)

DEFUSE 3 and DAWN TrialsNNT = 2.8

For every 2.8 patients treated with thrombectomy, 1 additional patient had

functional independence at 90 days

Return to caseEligibility based on time – LKW unclear? <12 hours

Current Literature: Hyper Acute Therapies for Acute Ischemic Stroke

IV tPA (recombinant tissue-type plasminogen activator)• NINDS trial (0-3 hours after LKW)• ECASSIII (3-4.5 hours after LKW)• EXTEND (4.5-9 hours after LKW with select patients with large territory still at risk)

Endovascular Mechanical Thrombectomy• MR CLEAN, REVASCAT, SWIFT PRIME, EXTEND-IA, ESCAPE (second-generation stent retriever device for

proximal thrombus up to 6 hours after LKW)• DAWN/DEFUSE3 (select patients with large territory still at risk, benefit from EVT up to 18/24h)

Provide the latest treatments for acute stroke and ICH: 24/7, 365 days a year

• Mechanical Thrombectomy• Endovascular treatment of aneurysms/AVMs

Complex Systems of Care in place to treat stroke patients safely and quicklyHeld to a higher standard of care for stroke patientsInvolved in Clinical Research

What does it mean to be a Comprehensive Stroke Center?

Stroke is an EMERGENCYLife saving and disability saving medication/therapy needs to be initiated within 24 hours

The sooner we restore blood flow the better chance of recovery

Treatment windows and options for therapy continue to expand

Advances in Acute Stroke CareTime is Brain

Advances in Acute Stroke CareDiagnostic Discrepancies:

1) Clinical presentation2) Time known/unknown since onset of symptoms3) Comorbidities/Previous history/Alternative acute diagnoses4) Degree of infarction at time of presentation5) Therapeutic pathway

Advances in Acute Stroke CareDiagnostic Discrepancies among:

1) Clinical presentation2) Time known/unknown since onset of symptoms3) Comorbidities/Previous history/Other acute diagnoses4) Degree of infarction at time of presentation5) Therapeutic pathway

Advances in Acute Stroke Care

Improved Outcomes:

Widespread Distribution of Advanced Diagnostic ImagingRefinements in Technique in Imaging

Speed in Diagnosis and CommunicationLarger Time Windows for Therapy

Validated Medical Therapy and Intervention


Improved Outcome:

Modified Rankin Scale90 day functionality following insult

0=Normal0-2= Can one live on one’s own

6=Dead


Interdisciplinary Cooperation

Emergency MedicineVascular NeurologyDiagnostic Radiology

Interventional RadiologyPost-Intervention Rehabilitation/Support


Diagnostic Imaging Algorithm:

Based on time of onset of symptoms

Availability of technology

Correlation between imaging and impact on therapy


Diagnostic Neuroimaging:

CT Brain without contrastCTA/Angiogram with contrast

CT Brain Perfusion


CT Brain without contrastCTA/Angiogram with contrast

CT Brain Perfusion

Evaluate the 4 Ps:Parnchyma

PipesPerfusion

Penumbra

Advances in Acute Stroke CareDiagnostic Discrepancies among:

1) Clinical presentation2) Time known/unknown since onset of symptoms3) Comorbidities/Previous history/Other acute diagnoses4) Degree of infarction at time of presentation5) Therapeutic pathway

Advances in Acute Stroke CareAcute stroke symptoms such as:

47 yo man stumbled out of his house 6AM for his coworker to pick him up for work. All he could say once getting into the car was “Holy Cow”. Friend thought he was acting strange, not talking much. Thought it was related to being early in the morning.

He is funneled into acute stroke pathway as a CODE STROKE pt

CT Brian without contrastNCCT

Advances in Acute Stroke CareHistory: “Holy Cow”

Parenchyma: Noncontrast CT brainIs there a visible abnormality?Cytotoxic edema, hemorrhage, tumor, chronic infarctionPresence or absence of abnormality on noncontrast brain imagingcan allow for rapid decision making in administration of IV tPa

Normal/No Acute FindingsExpected Findings in the settingof Acute Ischemic StrokeNo CT abnormality -12 hrs



Hemorrhage



Infection



Tumor



ASPECTS Score

Advances in Acute Stroke CareAlberta Stroke Program Early CT Score 10=Normal.

<5 poor outcome=/< 7 risk for complication with intervention

Advances in Acute Stroke CareAlberta Stroke Program Early CT Score. 10=Normal ASPECTS Score: 3


PIPES:CERVICAL AND INTRACRANIAL VESSELSNONCONTRAST CT BRAIN: DENSE MCA SIGNCT ANGIOGRAM HEAD AND NECK:LARGE VESSEL OCCLUSION (LVO)?STENOSIS, DISSECTION, VASCULAR MALFORMATION,DURAL VENOUS SINUS THROMBOSIS


PIPES:CERVICAL AND INTRACRANIAL VESSELSNONCONTRAST CT BRAIN: DENSE MCA SIGNCT ANGIOGRAM HEAD AND NECK:LARGE VESSEL OCCLUSION (LVO)?STENOSIS, DISSECTION, VASCULAR MALFORMATION,DURAL VENOUS SINUS THROMBOSIS


PERFUSION/PENUMBRAPOST CONTRAST DYNAMIC CT BAIN IMAGINGDYNAMIC WHOLE BRAIN SCANNING AS CONTRAST-ENHANCEDBLOOD ENTERS THE HEAD THROUGH LARGER VESSELS, DIFFUSES THROUGH SMALLER BRANCH VESSELS TOCAPILLARY LEVEL AND THENPASSES THROUGH DEEP AND CORTICAL VEINS,EXITS THROUGH DURAL VENOUS SINUSES


PERFUSION:ALLOWS FOR EVALUATION OF BRAIN HEMODYNAMICS BYMEASURING CHANGES IN DENSITY AS A FUNCTIONOF TIME-ATTENUATION CURVE.IN THE SETTING OF ACUTE ISCHEMIA, ALLOWS FOR RAPIDEVALUATION OF DECREASED OR COMPROMISED BLOODFLOW OR PERFUSION OF CEREBRAL TISSUE


PERFUSIONCEREBRAL BLOOD VOLUME MAP

NORMAL 4-5ML/100G

ISCHEMIA <1.5ML/100G

INFARCTED 1ML/100G

RELATIVE CBV <30% IRREVERSIBLY INJURED TISSUE"CORE INFARCT""


PERFUSION:CEREBRAL BLOOD FLOW:

NORMAL 50-60ML/100G/MIN

ISCHEMIA <25 ML/100G/MIN

INFARCTED <10ML/100G/MIN

RELATIVE CEREBRAL BLOOD FLOW MAP


PERFUSION:TIME TO MAXIMUM PERFUSION (TMAX)BLUE: 4-6 SECOND DELAYGREEN: 6-8 SECOND DELAYYELLOW: 8-10 SECOND DELAYRED: >10 SECOND DELAY

RED: POOR COLLATERAL FLOW, MORE RAPID PROGRESSIONTO INFARCTION

BLUE: MILD DELAY UNLIKELY TO GO ON TO INFARCT


PERFUSION:GREEN: DELAYED ARRIVAL OFCONTRAST OF MORE THAN 6 SECONDSLIKELY TO PROGRESS TO INFARCTIONIF REPERFUSION DOES NOT OCCUR

PINK: CEREBRAL BLOOD FLOW OF <30%, LIKELY TO BE IRREVERSIBLY INJURED

MISMATCH VOLUME: POTENTIALLY SALVAGEABLETISSUE

MISMATCH RATIO

Advances in Acute Stroke CareDiagnostic Imaging:Confirmed ischemia, excluded other diagnoses.

Imaging correlates with history time frame

Confirmed small to nonexistent core of irreversible injury, large penumbra of threatened, salvageable tissue

Call to Stroke/Vascular NeurologyCall to Interventional Radiology

Documents

Advances in Stroke Care - ogdensurgical.com · Case Presentation • Acute Ischemic Stroke Treatment Updates ... • Stroke is the #1 cause of disability • Approximately 795,000