![Page 1: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/1.jpg)
The Future of Stroke
Debbie Roper, RN, MSN
Vice President of Roper Resources, Inc.
James D. Fleck, M.D.
Medical Director
IU Health Methodist Hospital
Comprehensive Stroke Center
![Page 2: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/2.jpg)
Disclosures
Speaker for Genentech
Speaker for Chiesi
Independent Stroke Consultant
![Page 3: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/3.jpg)
Annual rate of first cerebral infarction by age, sex, and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1999).
Alan S. Go et al. Circulation. 2014;129:e28-e292
Copyright © American Heart Association, Inc. All rights reserved.
![Page 4: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/4.jpg)
Annual age-adjusted incidence of first-ever stroke by race.
Alan S. Go et al. Circulation. 2014;129:e28-e292
Copyright © American Heart Association, Inc. All rights reserved.
![Page 5: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/5.jpg)
Projected total costs of cardiovascular disease (CVD), 2015 to 2030 (2012 $ in billions) in the United States.
Alan S. Go et al. Circulation. 2014;129:e28-e292
Copyright © American Heart Association, Inc. All rights reserved.
![Page 6: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/6.jpg)
Treatment of Acute Ischemic
Stroke
Neuroprotection
Reperfusion
![Page 7: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/7.jpg)
Modified Rankin Score
0 = No symptoms at all
1 = No significant disability despite symptoms: able to carry out all usual duties and activities
2 = Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance
3 = Moderate disability: requiring some help, but able to walk without assistance
4 = Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance
5 = Severe disability: bedridden, incontinent, and requiring constant nursing care and attention
6 = Patient death
![Page 8: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/8.jpg)
Endovascular Ischemic Stroke Treatment
MR CLEAN - NEJM 2015; 372: 11-20
– Multicenter Randomized CLinical trial of Endovascular treatment
for Acute ischemic stroke in Netherlands
ESCAPE – NEJM 2015; 372: 1019-30
– Endovascular treatment for Small Core and Anterior circulation
Proximal occlusion with Emphasis minimizing ct to recanalization
times
EXTEND- IA – NEJM 2015; 372: 1009-18
– EXtending the time for Thrombolysis in Emergency Neurologic
Deficits
SWIFT – PRIME
– Solitaire FR With the Intention For Thrombectomy as PRIMary
Endovascular treatment for acute ischemic stroke
![Page 9: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/9.jpg)
Endovascular Ischemic Stroke Treatment
MR CLEAN – Netherlands
– Age > 18 yrs
ESCAPE – Canada / US / others
– Age > 18 yrs
EXTEND IA – Australia / New Zealand
– Age > 18 yrs
SWIFT PRIME – US / Europe
– Age 18-80 yrs
![Page 10: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/10.jpg)
Endovascular Ischemic Stroke Treatment
# Patients Mean
Age
Occlusion Time
Window
NIHSS
MR CLEAN IA – 233
Control 267
65y Distal ICA
or MCA or
ACA
IA < 6 hr < 2
Mean:
IA 17
Control 18
ESCAPE IA – 165
Control150
70-71y Distal ICA
or MCA
12 hr from
onset (15.5%
> 6 hr)
None at entry
Mean:
IA 16
Control 17
EXTEND IA IV – 35
IV/IA - 35
IV- 70 y
IV/IA – 69y
ICA or
MCA (1st or
2nd
segment)
IV < 4.5 hr
IA start < 6 hr
finish < 8 hr
None at entry
Mean:
IV 13
IV/IA 17
SWIFT
PRIME
IV – 98
IV/IA - 98
IV – 66y
IV/IA – 65y
Distal ICA
or
prox MCA
IA < 6 hr groin
puncture
8-29
Mean:
IV 17
IV/IA 17
![Page 11: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/11.jpg)
Endovascular Ischemic Stroke Treatment
Radiology
Inclusion
ASPECTS % patients
receiving iv
tpa
Median time
stroke onset
to iv tpa
MR CLEAN CTA/MRA Shows
occlusion
No inclusion
#
Median 9
IA 87.1%
Control
90.6%
85-87 min
ESCAPE NCCTASPECTS 6-10
CTAMod-good
collaterals
Median 9 IA 72.7%
Control
78.7%
IA 110 min
Control
125 min
EXTEND IA NCCT
CTA
CTP
100 % IV 145 min
IV/IA 127 min
SWIFT
PRIME
CTA/MRA Shows
occlusion
< 6 was
exclusion
100% IV 117 min
IV/IA 110 min
![Page 12: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/12.jpg)
Endovascular Ischemic Stroke Treatment
IA treatment retrievable
stent
IA
with
GA
Median
stroke
onset to
groin
Median
stroke onset
to
reperfusion
MR
CLEAN
Any type
mechanical
thrombectomy(Rare thrombolytic
agent)
81.5% 37.8% 260 min
ESCAPE Retrievable
stent
recommended (not mandated)
86.1% 9.1% 185 min 218 min
EXTEND
IA
Solitaire 100% 36% 210 min 253 min
SWIFT
PRIME
Solitaire 100% Stroke onset to first
deployment 252 min
![Page 13: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/13.jpg)
Endovascular Ischemic Stroke Treatment
90 day MRS 0-2 TICI 2b/3
MR CLEAN IA – 32.6%
Control – 19.%
OR 2.16 (1.39-3.38)
“Absence residual
occlusion”
IA – 75.4%
Control – 38.9%
ESCAPE IA – 53%
Control – 29.3%
OR 1.7 (1.3-2.2)
IA – 72.4%
EXTEND IA IV -40%
IV/IA – 71%
P = 0.01
IA -86%
SWIFT
PRIME
IV – 35.5%
IV/IA – 60.2%
OR 2.75(1.5-4.95)
IA – 88%
![Page 14: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/14.jpg)
Endovascular Ischemic Stroke Treatment
Symptomatic
ICH
Mortality
MR CLEAN IA – 7.7%
Control – 6.4%
30 day
IA – 18.9%
Control – 18.4%
ESCAPE IA – 3.6%
Control- 2.7%
IA – 10.4 %
Control- 19%
EXTEND IA IV- 6%
IV/IA – 0%
IV – 20%
IV/IA – 9%
SWIFT
PRIME
IV- 3.1%
IV/IA – 1.0%
IV – 12.4%
IV/IA – 9.2%
![Page 15: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/15.jpg)
Endovascular Ischemic Stroke Treatment
Do you have Interventional MDs and
teams?– At your hospital?
– At another hospital?
– Available 24/7/365?
– How do you access Interventional teams?
What advanced imaging is available?
Which patients receive advanced
imaging?
When do patients receive advanced
imaging?
![Page 16: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/16.jpg)
Mobile Stroke Units
Berlin, Germany
Univ Texas-Houston Medical School –
Houston, TX
Cleveland Clinic
![Page 17: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/17.jpg)
Mobile Stroke Units
![Page 18: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/18.jpg)
Mobile Stroke Units
![Page 19: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/19.jpg)
Mobile Stroke Units
Ambulance with CT scanner
Ambulance personnel
EMS organization
Point-of-care labs
Telemedicine connection
Cost
![Page 20: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/20.jpg)
Future of Stroke Care
![Page 21: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/21.jpg)
Future of Stroke Care
Bryan Morton, ReNeuron‘s chairman
• March 2014 - encouraging results of the Phase I
clinical trial of its REN001 treatment for disabled
stroke patients
• Phase II trial is now open for recruitment.
ww.reneuron.com/.../news_ReNeuron%202011%20interim%.
![Page 22: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/22.jpg)
Future of Stroke CareStroke Systems of Cares - Organization
– CSC
– PSC
– Acute Stroke Ready Hospital
– Acute Stroke Ready FSED by DNV
– State laws requiring where patients receive
care
Neuroprotection
– EMS deployment of meds
Enhancing recovery and rehabilitation
![Page 23: The Future of Stroke - American Heart Associationwcm/@mwa/documents/downloadable… · Median time stroke onset to iv tpa MR CLEAN CTA/MRA Shows occlusion No inclusion # Median 9](https://reader031.vdocuments.mx/reader031/viewer/2022041304/5e145029a3508d25257a4655/html5/thumbnails/23.jpg)
Questions?