Complex Stroke Cases and

Barriers in PSC and CSC

Marc A. Lazzaro, MD Assistant Professor of Neurology and Neurosurgery

Interventional and Vascular Neurology

Froedtert and Medical College of Wisconsin

June 14, 2013 Wisconsin Coverdell Stroke Program

Disclosures

• No financial interest in any product or manufacturer mentioned herein.

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

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

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

Benefit of CSC

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 1st time ischemic stroke

admitted to PSC/CSC vs general hospital

• Triage largely determined by geography

Meretoja A, et al. Stroke 2010; 41:1102-1107.

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; 41:1102-1107.

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

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.

Acute Stroke Case #1

Aneurysmal subarachnoid

hemorrhage case

• 30 year old woman

presented with “worst

headache of life” and

nausea.

• CT head showed

diffuse subarachnoid

hemorrhage

Aneurysmal subarachnoid

hemorrhage case

• Catheter angiogram showed a right

anterior choroidal artery aneurysm.

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

Muliple Critical Access Hospitals -Future “Acute Stroke Ready” Hospitals?

Wisconsin Stroke Centers

2 Comprehensive Stroke Centers

29 Primary Stroke Centers

Ideal regional stroke system elements

• Patient-centered

• Organized

• Standardized

• Fast

• Non-duplication of services

Stroke system models

• Trauma model

Trauma centers

Trauma centers (Level 1)

http://www.emergencymap.org/Trauma.aspx

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

Trauma centers

Trauma center transport times

45 minute transport zones to Level 1/2 (purple regions) • Air or ambulance • Base helipads

indicated by stars

Trauma center transport times

60 minute transport zones to Level 1/2 (purple regions) • Air or ambulance • Base helipads

indicated by stars

60 min stroke center access

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

60 min stroke center access

Tertiary referral to Comprehensive Stroke Center • Air transport

Primary stroke center

Comprehensive stroke center Regional Triage?

45 min ground transport to CSC in Milwaukee

60 min ground transport to CSC in Milwaukee

Triage, transport, transfer (T3) Tools

Triage by severity and time

Triage dilemma

• Patients need to be treated FAST

• Severely affected patients may benefit from a CSC

which may require longer transport.

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; 44:555-557

Early Recanalization

• The greatest benefit is achieved with EARLY IV tPA

administration (early recanalization)

– Greatest benefit within 90 minutes1

• 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;363:768-774

2. Rha JH et al. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007;38:967-73.

Optimizing revascularization

• Location of vessel occlusion is important

Small vessel occlusions

Optimizing revascularization

• Location of vessel occlusion is important

Medium and large vessel occlusions

Thrombolysis in small vessel

disease

• A good outcome from IV

thrombolysis is more common in

stroke due to small vessel disease

than other subtypes1

– 957 patients treated with IV tPA

Stroke Subtype n Excellent outcome, mRS 0-1

Large artery atherosclerosis 217 (23%) OR 0.69 [CI 0.5 – 0.96]

Cardioembolic 389 (41%) OR 0.80 [CI 0.61 – 1.06]

Small vessel disease 101 (11%) OR 2.48 [CI 1.63 – 3.79]

Other 27 (2.8%) OR 0.32 [CI 0.11 – 0.94]

Undetermined 130 (14%) OR 1.85 [CI 1.27 – 2.70]

1. Mustanoja, S et al. Outcome by stroke etiology in patients receiving thrombolytic treatment: Descriptive Subtype Analysis. Stroke. 2011;42:102-106

Optimizing revascularization

• Distal vessel occlusions are more likely to

recanalize with IV tPA than larger proximal

vessels1

• 335 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 0.7 49 of 163 (30%)

Terminal ICA 0.1 1 of 17 (5.9%)

Tandem cervical ICA and MCA

0.7 6 of 22 (27%)

Basilar 0.96 3 of 10 (30%)

1. Saqqur, M et al. Site of arterial occlusion identified by TCD predicts response to IV thrombolysis for stroke. Stroke. 2007; 38:948-954.

ENDOVASCULAR THERAPY

Time-Location Based Recanalization

0 3 4.5 8 6 Hours

Clot

Location

Small Vessel

Large Vessel

IV tPA

IA -tPA

MECHANICAL THROMBECTOMY

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

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;119:2235-2249

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; 44:555-557

Triage by severity and time

Grotta JC. Stroke 2013; 44:555-557

Tiered regional EMS triage

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

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

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

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

Thank you for your attention

Marc Lazzaro, MD