National Acute Stroke ProtocolStandard of Care & Emerging Technology

Thomas F. Osborne, MDNeuroradiologist @ Virtual Radiologic, Director of Medical Informatics @Virtual Radiologic, Director Of Research @ MEDNAX

Third Annual Clinical Geriatrics Interprofessional Symposium 12/3/16

Financial Disclosure

I do not have direct or indirect financial interest in the equipment or medications

discussed in this lecture

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Patient Presentation

• Provided History: • Patient with AMS ? CVA

• What do you do next?

Photo credit:New York Times: Collect Debts, Nursing Homes Are Seizing Control Over Patients. Jan 25, 2015

What is happening to my wife!?What can we do?What is going to happen next?

Reference: www.strokeassociation.orgwww.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Clinical-Resources-and-Tools_UCM_432411_Article.jsp#.WDqqbTHrucm

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Reference: www.strokeassociation.org

Heart disease and stroke statistics—2014 update: http://circ.ahajournals.org/content/early/2013/12/18/01.cir.0000441139.02102.80

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Hippocrates• Saw stroke as an act of swift

and terrible violence by the gods (to strike -- a stroke).

• Poorly understood, it came to be called "apoplexy," derived from the Greek for "crippling stroke" as from a powerful weapon.

• For centuries, apoplexy was generally used to describe any act of paralysis.

460 BC –370 BC

Thomas Osborne, MD

Johann Jacob Wepfer• Hypothesized from his autopsy

studies that stroke was due to bleeding in the brain.

• The first to suggest stroke might be caused by a blockage in a blood vessel.

• 1658 published a classic treatise regarding strokes, titled Apoplexie.

1620 -1695

Thomas Osborne, MD

Rudolf Ludwig Carl Virchow:Virchow’s triad (as a model) though technically a venous concept

• Vascular endothelial injury• Hypercoagulability• Stasis

Schiller F. Concepts of stroke before and after Virchow. Medical history. 1970 Apr 1;14(02):115-31.

1821– 1902

Cause of Ischemic Stroke

ASD, PFO, VSDASD, PFO, VSD

Vascular endothelial injury

Stasis

Hypercoagulability (all)

Other causes: Vasospasm (SAH, Rx) chronic meningitis, arteritis, Moya-moya, cardiac arrest, etc.

Reference: Fisher M, Dávalos A, Rogalewski A, Schneider A, Ringelstein EB, Schäbitz WR. Toward a multimodal neuroprotective treatment of stroke. Stroke. 2006 Apr 1;37(4):1129-36.

Core

Penumbra

Thomas Osborne, MD

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/terms

6. Prehospital EvaluationThomas Osborne, MD

Thomas Osborne, MD

• Earliest recanalization attempts failed• Before CT and many pts after 6h + Hemorrhage• By the 1970’s considered too dangerous

• 1980’s success in other areas renewed interest• PE, MI, & better cath design

• 1980-1990 trials and errors• (ASK) Australian Streptokinase Trial• (MAST-E) Multicenter Acute Stroke Trial-Europe• (MAST-I) Multicenter Acute Stroke Trial-Italy• (ECASS) European Cooperative Acute Stroke Study• NINDS 1995 rtPA Stroke Study

• B/c the NINDS study, in 1996 FDA approved tPA» National Institute of Neurologic Disorders and Stroke» tissue recombinant plasminogen activator (fibrinolytic)

NINDS Summary (National Institute of Neurologic Disorders and Stroke)

– Don’t give tPA if head CT = risk for bleed – If you give IV tPA before 3 hr = pts do better– If you give after 3 hr = inc risk for ICH

Reference:Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;14;333:1581-1587.

Reference: Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR. Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar 1;44(3):870-947.http://stroke.ahajournals.org/content/44/3/870

Time Goals

67yo M c 2h of AMS weakness

Initial Question: Is it a stroke or stroke mimic?

– Hypoglycemia, Seizure, Bell’s palsy, Rx, ICH, MS, Migraine, Thiamine Deficiency, Tumor, Infection, underlying medical illness, other illness…

Baseline condition?

Photo credit: New York Times

Interdisciplinary Collaborative TeamCode stroke called in field

Immediate/EMS: NIH Stroke Scale, initial labs & Hx of contraindicationsAcute triage and directly to CT scan

Pt eval in ED or in CT. Premix tPA

Rapid CT eval and rapid Rx (in CT room)

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

http://stroke.ahajournals.org/content/44/3/870

Reference: Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR. Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar 1;44(3):870-947.http://stroke.ahajournals.org/content/44/3/870

* A physician with expertise in acute stroke care may modify this list.

Reference: Jauch EC, Saver JL, Adams HP, Bruno A, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR. Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar 1;44(3):870-947.http://stroke.ahajournals.org/content/44/3/870

CT Exclusion criteria for tPA

ECASS I, NINDS

Following 3 slides:Best practice quick references

with links

Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/heart-public/@wcm/@gwtg/documents/downloadable/ucm_470145.pdf

Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/stroke-public/@private/@wcm/@hcm/@gwtg/documents/downloadable/ucm_431633.pdf

Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/heart-public/@wcm/@gwtg/documents/downloadable/ucm_470723.pdf

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Stroke Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Additional Diagnostic OptionsThese should not delay Rx with IV rtPA

• CTA (need for IA Rx) • MRI• Perfusion (MRI or CT)

Thomas Osborne, MD

Key Time Windows• Time matters (time is brain)

– 3 hour window (IV) FDA approved

• (or 4.5 hr window)• Hacke W,Kaste M,Bluhmki E,Brozman M,Dávalos A,Guidetti D,Larrue V,Lees KR,Medeghri Z,Machnig T,Schneider D,von Kummer R,Wahlgren N,Toni

D; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–1329.

– 6 hour window (IA)• Ogawa A,Mori E,Minematsu K,Taki W,Takahashi A,Nemoto S,Miyamoto S,Sasaki M,Inoue T; MELT Japan Study Group. Randomized trial intraarterial

infusion of urokinase within 6 hours of middle cerebral artery stroke: the Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan. Stroke. 2007;38:2633–2639.

• Furlan A,Higashida R,Wechsler L,Gent M,Rowley H,Kase C,Pessin M,Ahuja A,Callahan F,Clark WM,Silver F,Rivera F. Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial: Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282:2003–2011

– 8 hour window (mechanical)• Saver JL,Jahan R,Levy EI,Jovin TG,Baxter B,Nogueira RG,Clark W,Budzik R,Zaidat OO; SWIFT Trialists. Solitaire flow restoration device versus the

Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380:1241–1249• Nogueira RG,Lutsep HL,Gupta R,Jovin TG,Albers GW,Walker GA,Liebeskind DS,Smith WS; TREVO 2 Trialists. Trevo versus Merci retrievers for

thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial [published correction appears in Lancet. 2012;380:1230]. Lancet. 2012;380:1231–1240

– 12-48 hour window

Stroke Perfusion Imaging

Moving from a time to a physiology paradigm

Thomas Osborne, MD

R2* = -ln s (baseline)

s (t)

TE

{ }AUC = CBV

Deconvolution

AIF

CBFCBV

MTT =

SI curve to Concentration curve

Peak = CBF

Residue Function

SI

larrylakey.com

Core

Penumbra

Thomas Osborne, MD

Basic PathophysiologyCore-Penumbra

Maximal Vasodilation

Acute Ischemic Stroke. Gonzalez et al. 2006 Thomas Osborne, MD

Core (DWI)PenumbraSeverely dec flowRapid irreversible damage -Excitotoxic -Necrotic cell death

Ischemic but noninfarctedPotentially salvageableCollateral supportCell death slowerSize = physiology -(Huge target for Rx)

Sometimes just perfusion defect -TIA, carotid stenosis

Basic Pathophysiology

Thomas Osborne, MD

Perfusion Physiology

1

Thomas Osborne, MD

Perfusion Physiology

2

Thomas Osborne, MD

Perfusion Physiology

3

Thomas Osborne, MD

Perfusion Physiology

4

Thomas Osborne, MD

Thomas Osborne, MD

What you are looking for?DWI vs MTT mismatch

(DWI vs. NIH Stroke Scale mismatch)

DWI ADC MTT

Vs

Thomas Osborne, MD

CBV TTP

CBF MTT Delayed

Lecture Outline

1. Patient Presentation

2. Stroke Stats

3. Pathophysiology

4. Rx / National Stroke Protocol

5. Advanced Technology/Terms

6. Prehospital EvaluationThomas Osborne, MD

Reference: www.strokeassociation.orgwww.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Clinical-Resources-and-Tools_UCM_432411_Article.jsp#.WDqqbTHrucm

Reference: Journal Stroke. Guidelines for the Early Management of Patients With Acute Ischemic Strokehttp://stroke.ahajournals.org/content/44/3/870

Summary1. Patient Presentation

• What to look for and answering immediate questions

2. Stroke Stats• 4th-5th common cause of death. 1 stroke/40 seconds

3. Pathophysiology• Emboli, Ischemia and Infarction

4. Rx / National Stroke Protocol• tPA 3 hours from onset

5. Advanced Technology/Terms• Imaging physiology: Core and Penumbra, Stroke Scale

6. Prehospital Evaluation• Time is brain

Thomas Osborne, MD

Thomas Osborne, MD