advances in stroke care - ogdensurgical.com · case presentation • acute ischemic stroke...
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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
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
Advances in Acute Stroke Care
Improved Outcome:
Modified Rankin Scale90 day functionality following insult
0=Normal0-2= Can one live on one’s own
6=Dead
Advances in Acute Stroke Care
Interdisciplinary Cooperation
Emergency MedicineVascular NeurologyDiagnostic Radiology
Interventional RadiologyPost-Intervention Rehabilitation/Support
Advances in Acute Stroke Care
Diagnostic Imaging Algorithm:
Based on time of onset of symptoms
Availability of technology
Correlation between imaging and impact on therapy
Advances in Acute Stroke Care
Diagnostic Neuroimaging:
CT Brain without contrastCTA/Angiogram with contrast
CT Brain Perfusion
Advances in Acute Stroke Care
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
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
Hemorrhage
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
Infection
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
Tumor
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
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
Advances in Acute Stroke CareHistory: “Holy Cow”
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
Advances in Acute Stroke CareHistory: “Holy Cow”
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
Advances in Acute Stroke CareHistory: “Holy Cow”
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
Advances in Acute Stroke CareHistory: “Holy Cow”
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
Advances in Acute Stroke CareHistory: “Holy Cow”
PERFUSIONCEREBRAL BLOOD VOLUME MAP
NORMAL 4-5ML/100G
ISCHEMIA <1.5ML/100G
INFARCTED 1ML/100G
RELATIVE CBV <30% IRREVERSIBLY INJURED TISSUE"CORE INFARCT""
Advances in Acute Stroke CareHistory: “Holy Cow”
PERFUSION:CEREBRAL BLOOD FLOW:
NORMAL 50-60ML/100G/MIN
ISCHEMIA <25 ML/100G/MIN
INFARCTED <10ML/100G/MIN
RELATIVE CEREBRAL BLOOD FLOW MAP
Advances in Acute Stroke CareHistory: “Holy Cow”
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
Advances in Acute Stroke CareHistory: “Holy Cow”
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