acute care telemedicine

“Connect to Quality”


Beyond tPA: Teleneurology for This

DecadeMatthews Gwynn, MD

AcuteCare Telemedicine

2012 GPT Annual Conference

2Connect to Quality

Stroke Facts

Connect to Quality 3

• A leading cause of death in the United States

• 795,000 Americans suffer strokes each year

• 134,000 deaths each year

• From 1996 to 2006, the stroke death rate fell 33.5% and number of deaths fell by 18.4%

• 6,400,000 stroke survivors



Stroke-Related Death Rates Rank out of 50 States Deaths per 100,000

Tennessee51 58.1 Alabama 50 56.3 Mississippi 46 53.3 Louisiana 45 52.6 Georgia 44 51.5 Florida 41 35.3

American Heart Association; Heart Disease and Stroke Statistics, 2011 Update



Stroke Belt


“Connect to Quality” 6Connect to Quality


Harrison’s Medical Textbook -1954


“There is no satisfactory medical treatment…..”


Stroke Treatment - 1954


“….treatment with intravenous tPA within 3 hours...improved clinical outcome at 3 months.”


A New Era - 1995



Telemedicine Endorsed by American Stroke Association


The Future of Stroke Care: Multi-Hospital Acute Stroke Network in

Georgia

Emory University School of MedicineMarcus Neuroscience and Stroke Center

Grady Memorial Hospital

Connect to Quality 12“Connect to Quality”

Marcus Stroke Center Mission• To develop a collaborative model with primary stroke centers

and a hub comprehensive stroke center that offers endovascular capabilities, along with critical care and clinical trial expertise

• To help improve clinical outcomes for patients with large vessel occlusive diseases

• To advance scientific knowledge and treatment paradigms through clinical trials

• To help with community education programs and develop rapid emergency response services for stroke



The Future of Stroke: Thrombectomy

• 55 year old man presented to outside hospital with an acute onset of left sided hemiplegia, right gaze preference and neglect.

• He was last known normal at 3:30 pm, and his wife attempted to wake him up at 5:15 pm and contacted EMS

• He was brought to outside facility and a CT of the brain was negative for hemorrhage and thus IV tPA was administered at 7:05 pm.

• Marcus Center contacted for possible transfer

• While transportation being arranged, family discussions regarding endovascular options and contacting of endovascular team and anesthesia



• Upon arrival a CT of the brain was repeated at 8:43 pm and did not reveal significant early ischemic changes

• Patient taken emergently to angiography

• While anesthesia sedating patient, family meeting regarding risks of endovascular therapy and enrollment into a clinical study

• Family agreed to proceed

• Groin Puncture at 9:19 pm

• First angiogram at 9:26 pm and clot retrieved at 9:47 pm


Lateral projection pre-treatment

Collaterals noted in delayed manner


No Right Middle Cerebral Artery Flow


AP view pre-treatment Collaterals noted


No Right Middle Cerebral Artery Flow


At 24 hours, the patient noted to have a NIHSS of 0; Discharged to home at 48 hours


• A 69 year old man with a history of atrial fibrillation on Pradaxa who was last known normal at midnight. A thud was heard at 10 am.

• The patient was taken to a rural Georgia hospital ER and was evaluated by AcuteCare teleneurologist.

• He was found to have on exam right sided weakness, difficulty speaking and left gaze preference.

• Because not a tPA candidate because of anticoagulation, after normal CT he was transferred to Marcus Stroke Center

Recent AcuteCare Telemedicine Case


Angiogram showed a left MCA occlusion. He was treated with one pass of the Merci V2.5 soft retriever to achieve reperfusion.


Post procedure the patient is noted to have 4/5 strength in the right arm and leg, improved gaze preference and improved speech.


ACOs and Teleneurology• About $500,000 to attract, hire, and retain a neurologist

for a year• Need at least two neurologists to cover continuously • ACO success depends on reducing costs of physicians• “Fractional neurology” for 24/7 coverage is more

affordable and sufficient• In partnership with thrombectomy centers, long-term

rehabilitation and medical costs will decrease• Teleneurology will be valuable for ACOs


The Partners of AcuteCare Telemedicine Thank You for Your

Attention


acute care telemedicine

Health & Medicine

stroke facts

stroke belt

stroke treatment

future of stroke care

american stroke association

strokerelated death

marcus stroke center

harrisons medical textbook