stroke in india: disease, systems, and treatment
TRANSCRIPT
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Stroke in India: Disease, systems, and Treatment – Interventional Treatment
Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon
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MR CLEAN TrialNetherlands, 2015
ESCAPE TrialCanadian, 2015
EXTEND-IA TrialAustralian, 2015
SWIFT PRIME TrialUSA, 2015
REVASCAT TrialSpanish, 2015
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AHA/ ASA guideline 2015:Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
prestroke mRS score 0 to 1 acute ischemic stroke receiving intravenous r-tPA within 4.5
hours of onset causative occlusion of the internal carotid artery or proximal
MCA (M1) age ≥18 years NIHSS score of ≥6 ASPECTS of ≥ 6 treatment can be initiated (groin puncture) within 6 hours of
symptom onset
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Etiology (Indian scenario) Large-artery atherosclerosis – 41% Lacunar - 18% Cardioembolic - 10% Rare – 4% Undetermined etiology – 27%
Kaul S, Sunitha P, Suvarna A, Meena AK, Uma M, Reddy JM. Subtypes of ischemic stroke in a metropolitan city of south India (one year data from hospital based stroke registry). Neurol India. 2002;50(suppl 1):S8–S14.
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ICAD
ICAD incidence - 12% (53/448) amongst ischemic strokes.
Prevalence (TCD – PSV > 140) – 7% in asymptomatic but with vascular risk factors
Kate M et al. Imaging and Clinical Predictors of Unfavorable Outcome in Medically Treated Symptomatic Intracranial Atherosclerotic Disease. J Stroke Cerebrovasc Dis 2014.
Sada S et al. Neurology India. 2014.
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Indian Experience With Mechanical Thrombectomy STROKE TREATMENT CENTERS:
Thrombolysis: approx. 100 centers
Population 1,336,286,256 (July 2016 est.)Density 383 people per.sq.km (2011 est.)
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Total acute stroke: 1096 (March 2002-2006) Acute ischemic stroke: 877 Thrombolysis: 54 (6.1%)
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Indian Experience With Mechanical Thrombectomy
Status of Mechanical ThrombectomyAround 60 centers across country of 1.34 billion.
Among 967 patients enrolled in the on-going Indo-USA Collaborative National Stroke Registry, 134 patients came within 4.5 hours and 104 (11%) patients received r-tPA. Intra-arterial and mechanical thrombolysis was given in 34 (3.5%) patients.
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Indian Experience With Mechanical Thrombectomy
Study period: 2009-2013Total cases: 45
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Indian Experience With Mechanical Thrombectomy
STATUS OF MECHANICAL THROMBECTOMYPublic Sector:
AIIMS (New Delhi): 24 cases/Year.
PGIMER (Chandigarh): 18 cases/Year
SCTIMST (Thiruvanthapuram):24-30 cases /Year
NIMHANS (Bangalore): 10-12 cases/year
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Indian Experience With Mechanical Thrombectomy
STATUS OF MECHANICAL THROMBECTOMY• Private Sector:
–New Delhi (single largest center): 26 cases 2015.
–Bangalore (single center): 24 cases 2015.
–Mumbai (two centers): 53 cases 2015
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2013 2014 20150
50
100
150
200
250
Stent - retriever
Stent - retriever
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Indian Experience With Mechanical Thrombectomy
STATUS OF MECHANICAL THROMBECTOMY
Sale figures:
• Company A: 138.3 devices.
• Company B: 80devices.
• Company C: 45 devices.
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Challenges …. Lack of training programs - guidelinesInsurance Stroke team Support from institutions Private sector – demand drivenPublic awareness (medical community)Timing issue
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Training challenges
Dedicated training - 2 years vs ….Disciplines (Radiology, Neurology and
Neurosurgery)Centers that can train (what nos. ?)To maintain skill ??Accreditation board (STNI …)
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DM Neuroradiology program centers:• AIIMS• PGI• NIMHANS• SCTIST
University • SRMC• KMC • Vellore
Fellowship program• Artemis• Medanta• MSSH • KEM Pune • Mumbai • Others….
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Way ahead …Arrive at an consensus Start society authorized training program – based on minimum requirements
Approach MCI and NBE
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Challenges ….Trained neurointerventionists Infrastructure Stroke team Support from institution/hospital FinancePublic awareness Timing issue
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Solutions..
Program viability – aneurysms, AVMs …Overlap with neurosurgery for aneurysm, AVMs..
Overlap with neurology for ischaemic stroke …
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Round the clock services INR - Three faculty – two radiology and one from
stroke neurology background . We also provide emergency services to selected centres
The stroke neurologist INR takes care of all stroke patients
Overlapping – neurology-stroke-INR teamBased on group practice One fellow – Stroke-INR fellowship
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TechsEncouraged to stay nearby Training program
Anesthesia and critical care NI program is part of clinical neurosciencesActive – neurovascular program – SAHNeuroanesthesia provide cover as for HI etc
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Financial barrierMost patients don’t have insurance They have to be explained in simple clear terms Major stroke, MVO, we can try to save brain, 70%
recanalization; 50% good outcome at 3-months; risk of bleed /decompression
Based on written commitment Show them picturesDetailed counseling everyday on written form Device write off….
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Promoting stroke intervention program – awareness
Stroke training program for physiciansEncouraged to take opinions (social media)Neurology services to selected centers Public lectures – Rotary, Loin clubsStroke week Media TestimonialsLearning from cardiologists …
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•The Interventional Management of Stroke pilot trials tested combined IV/IA therapy onset.
•Among the 54 cases, only time to angiographic reperfusion and age independently predicted good clinical outcome after angiographic reperfusion.
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TIME for recanalization• Onset to door time
• Door to Imaging/picture
• Picture to puncture (P2P)
• Puncture to recanalization time
Hospital processes
Technical skills
• Onset to puncture/groin time
• Onset to recanalization time
• Door to Puncture (D2P)
• Picture to recanalization (P2R)
Society infrastructure
Ultimate predictor
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One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed.
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• Parallel Processing, Trust, and Teamwork
• Fast Minimalist Clinical Examination
• Fast, Minimalist Imaging Based on a Decision- Based Paradigm; No Complex Post Processing of Imaging
• No General Anesthesia
• Use the CT Angiography to Plan the Procedure
• Setting Up the Angiography Room – tech, INR, material
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Physician Guide – Protocol based
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Timing • Protocol• Sessions with emergency,
radiology, critical care teams• Dedicated team – INR• Monitoring
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CTMRI
EDD
SA
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Times pre and post implementation of parallel processing:
Picture to Puncture time: PRE Mean: 80 minutes (21 – 260) POST Mean: 60 minutes (30 – 140)
(Median – 50 minutes)
Puncture to reperfusion
POST Median 42 minutes (12 – 120)DSA next door and direct to suite – P2P – further 30 minute reduction achieved with a mean of 3o minutes
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Our resultsTotal No. of patients= 42 (M-19, F- 23) Time of arrival: 30 min- 840 min (mean 203.8 minutes) NIHSS at admission: 5-22 (Mean 14.33) MVO 39, IV tPA- 19
Good recanalization (TICI 2b or 3) in 57.1%mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)
Recanalization V/s Outcome
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Mechanical thrombectomy in India
• National guidelines • Training programs – consensus • Local solutions • Monitoring of results• Awareness ….learning from cardiology
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Thank you ….