Comprehensive Stroke Update

Annette Davis

Acute Care Nurse Practitioner

Neuro Endovascular Surgery

Department of Neurosurgery

OBJECTIVES

1. Understanding Stroke today

2. Recognizing stroke: AIS, ICH and SAH

3. Understanding the evidence and current guidelines for AIS intervention: Thrombolysis & mechanical thrombectomy

4. Discuss secondary stroke prevention and recovery

5. Apply knowledge of stroke principles as they pertain to case studies

Stroke Statistics

Stroke Statistics

• Someone in the US has a stroke about once every 40 seconds.

• Each year, about 795,000 people experience a new or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent attacks.

• Stroke accounts for 1 of every 19 deaths in the US.

• Stroke kills someone in the US about every 3 minutes 45 seconds.

• When considered separately from other cardiovascular diseases, stroke ranks No. 5 among all cause of death in the US, killing nearly 133,000 people a year.

• In 2015, stroke deaths accounted for 11.8% of total deaths worldwide, making stroke the second leading global cause of death behind heart disease.

• From 2005 to 2015, the age-adjusted stroke death rate decreased 21.7%, and the actual number of stroke deaths declined 2.3%.

• Stroke is a leading cause of serious long-term disability in the US.

http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp#.XEZC_62Wypq

Mortality 20% higher in the stroke belt, and even higher at 40% in the buckle

Stroke Rates

STROKE

Race or Ethnicity Ischemic Stroke Death Rate per 100,000

State National

All Races/Ethnicities 220.5 182.9

Black (Non-Hispanic) 313.2 269.9

White (Non-Hispanic) 201.5 178.3

Hispanic Insufficient Data 146.7

American Indian and Alaskan Native

Insufficient Data 146.5

Asian and Pacific Islander Insufficient Data 153.8

South Carolina Summary Statistics

Ischemic Stroke Death Rate per 100,000, 65+, All Races/Ethnicities, Men, 2005-2007

STROKE

Race or Ethnicity Ischemic Stroke Death Rate per 100,000

State National

All Races/Ethnicities 156 132.1

Black (Non-Hispanic) 225.9 185.9

White (Non-Hispanic) 143.4 130.7

Hispanic Insufficient Data 108.4

American Indian and Alaskan Native

Insufficient Data 106.1

Asian and Pacific Islander Insufficient Data 94.7

South Carolina Summary Statistics

Ischemic Stroke Death Rate per 100,000, 65+, All Races/Ethnicities, Men, 2014-2016

Race or Ethnicity Ischemic Stroke Death Rate per 100,000

State National

All Races/Ethnicities 45.7 37.9

Black (Non-Hispanic) 60.1 52.1

White (Non-Hispanic) 42.3 37.6

Hispanic 19.6 28.3

American Indian and Alaskan Native

Insufficient Data 31.1

Asian and Pacific Islander 30.7 25.9

South Carolina Summary Statistics

Ischemic Stroke Death Rate per 100,000, 35+, All Races/Ethnicities, Both Genders, 2014-2016

SC Ischemic Stroke

SC Hemorrhagic Stroke

Race or Ethnicity Hemorrhagic Stroke Death Rate per 100,000

State National

All Races/Ethnicities 21.9 17.6

Black (Non-Hispanic) 29.8 23.5

White (Non-Hispanic) 19.3 16.6

Hispanic 15.6 16.1

American Indian and Alaskan Native

Insufficient Data 16.7

Asian and Pacific Islander Insufficient Data 19.5

Hemorrhagic Stroke Death Rate per 100,000, 35+, All Races/Ethnicities, Both Genders, 2014-2016

South Carolina Summary Statistics

Stroke is a leading cause of functional impairment. For patients who are ≥65 years of age, 6 months after stroke, 26% are dependent in their activities of daily living, and 46% have cognitive deficits. Stroke changes the lives not only of those who experience a stroke but also of their family and other caregivers.

Modified Rankin Scale

Defining Stroke

An acute loss of neurological

function due to an abnormal perfusion of brain tissue

Acute Ischemic Stroke

Interruption of cerebral blood flow results in decreased

energy production, which in turn causes failure of ionic

pumps, mitochondrial injury, activation of leukocytes (with

release of mediators of inflammation), generation of

oxygen radicals, and release of excitotoxins. Increased

cellular levels of sodium, chloride, and calcium ions result

in stimulation of phospholipases and proteases, followed

by generation and release of prostaglandins and

leukotrienes, breakdown of DNA and the cytoskeleton,

and ultimately, breakdown of the cell membrane.

Alteration of genetic components regulates elements of

the cascade to alter the degree of injury. AMPA denotes

alpha-amino-3-hydroxy-5-methyl- 4-isoxazole propionic acid and NMDA N - methyl-D-aspartate.

Pathophysiology of AIS

The Molecular Events Initiated in Brain Tissue by Acute Cerebral

Ischemia.

Case Study

Ima Clott, 65 yo female with pmhx HTN, HLD, DM, CAD, GERD and AF presents to ED at 0930 am via EMS after family discovers her on floor.

She has right sided weakness, left gaze preference and aphasia. Last known normal was 8:00 am today. She underwent colonoscopy one day ago, unremarkable findings.

VS: Temp 97.7, HR 110, irregular; BP 212/105

RR 28, O2 sat 99% 2L NC.

Medications: Lisinopril, Simvastatin, Metoprolol, Tramadol, Neurontin, and Xarelto (on hold for 2 weeks for colonoscopy)

Recognizing AIS

TIA

A focal neurological deficit lasting 24hours

*A brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of infarction.

*TIAs are an important determinant of stroke, with 90-day risks of stroke reported as high as 10.5% and the greatest stroke risk apparent in the first week.

*Risk factor control is primary focus in the event of a TIA

Consider Stroke DifferentialsSeizure

Electrolyte disorder

Hypo/Hyperglycemia

Meningitis, encephalitis or systemic infection

Intracranial neoplasm

Conversion Disorder

Complex or atypical Migraine

NIH Stroke Scale

• https://archive.org/details/gov.hhs.ninds.stroke.1.7

Large vessel vs Lacunar

Large Vessels of the Brain

Large Vessel Occlusion

Symptoms of LVO

Cortical Signs

Lacunar Stroke

Functional Anatomy of Brain

Vascular Territory Symptoms

ICACombined ACA and MCA symptoms, may have transient central retinal

artery occlusion (amaurosis fugal)

Left ACA Right leg numbness and weakness, may have transcortical aphasia

Right ACA Left leg numbness and weakness, motor neglect

Left MCA Right face, arm numbness and weakness, aphasia, left gaze preference

Right MCALeft face, arm, numbness and weakness Moree than leg, left neglect,

right graze perference

Left PCAComplete or partial right HH, Alexia without agraphia, may have 3 rd

nerve palsy

Right PCA Complete or partial left HH, may have 3rd nerve palsy

Vertebral/cerebellar Upsidesional limb and gat ataxia

Basilar Impaired lateral gaze, horizontal diplopia, disconjugate gaze

Case Study

Ima Clott, 65 yo female with pmhx HTN, HLD, DM, CAD, GERD and AF presents to ED at 0930 am via EMS after family discovers her on floor.

She has right sided weakness, left gaze preference and aphasia. Last known normal was 8:00 am today. She underwent colonoscopy one day ago, unremarkable findings.

VS: Temp 97.7, HR 110, irregular; BP 212/105

RR 28, O2 sat 99% 2L NC.

Medications: Lisinopril, Simvastatin, Metoprolol, Tramadol, Neurontin, and Xarelto (on hold for 2 weeks for colonoscopy)

Cerebral Circulation

EMS Pre notification Stroke Scales Rapid Triage

Single Call activation

Transfer directly to CT

Rapid Acquisition and interpretation of brain imaging

Rapid labsMix tpa ahead of

timeRapid access and

administration

Acute Stroke Treatment

TIME is BRAIN

Options for Patients Experiencing an Ischemic Stroke

Endovascular Clot Removal

Mechanical disruption or removal of the clot using standard endovascular

approaches

IV tPAGold-standard in ischemic

stroke care. Drug is designed to break apart the clot.

Medical Management

Monitor vitals and provide secondary stroke prevention.

Bridging Therapy

Timeline Goals of Acute Intervention

https://neupsykey.com/acute-stroke-the-first-hour/

Initial CT Review:

https://teddybrain.wordpress.com/2013/02/11/time-course-of-ischemic-stroke-on-non-enhanced-ct/

TPA: Mechanism of Action

5 minute half life, 45 minute terminal half life

Follow up with frequent neurological checks

http://usmle.biochemistryformedics.com/immediate-treatment-of-acute-mi/

• tPA is recommended for selected patients who

may be treated within 4.5-hours of stroke-

symptom onset

• tPA dosing:

• 0.9 mg/kg, max dose of 90 mg

• 10% given as a bolus over 1 minute• Remaining given over 60 minutes

TPA: Administration Standard dosing, 0.9

mg/kg

10% initial bolus, then remaining over 1 hour

Drip and ship

Promotes thrombolysis which may result in reperfusion of salvageable brain

Consent patient or family of 6% risk of bleed, approximately 1/2 of which are fatal

https://resusreview.com/2013/tpa-mixing-tutorial/

Treatment of AIS: IV Administration of Alteplase

• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min

• Admit the patient to an intensive care or stroke unit for monitoring. If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan.

• Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment.

• Increase the frequency of BP measurements if SBP is >180 mm Hg or if DBP is >105 mm Hg; administer antihypertensive medications to maintain BP at or below these levels

• Obtain a follow-up CT or MRI scan at 24 h after IV alteplasebefore starting anticoagulants or antiplatelet agents.

CT PERFUSION

CT PERFUSION

Emergent Thrombectomy

Recanalization with Mechanical Thrombectomy

Thrombectomy Trials

MR CLEAN 2010

REVASCAT2012

EXTEND2012

SWIFTPRIME2012

ESCAPE 2013

THRACE2010

THERAPY2012

PISTE2013

EASI2013

EMERGENT THROMBECTOMY FOR LVO

RECANNALIZATION SCORE

TICI 0 No antegrade flow beyond point of occlusion

TICI 1 The contrast material passes beyond the area of obstruction but fails to opacify the entire cerebral bed distal to the obstruction for the duration of the angiographic run

TICI 2a The contrast material passes beyond the obstruction and opacifies the arterial bed distal to the obstruction; however, the rate of entry of contrast into the vessel distal to the obstruction or its rate of clearance from the distal bed or both are perceptibly slower than its entry into and/or clearance from comparable areas not perfused by the previously occluded vessel (eg, the opposite cerebral artery or the arterial bed proximal to the obstruction); less than two-thirds of the entire vascular territory is visualized; for example, in a patient with an M1 segment occlusion the M1 may have normal flow but at least 1 M2 segment remains occluded

TICI 2b Same as TICI 2a, except flow is seen into two-thirds or more of the expected vascular tree but is slower than normal; for example, in a patient with an M1 segment occlusion, all M2 branches proximally are open with areas of small segmental distal occlusion or slow flow

TICI 3 Complete perfusion; antegrade flow into the bed distal to the obstruction occurs as promptly as into the obstruction and clearance of contrast material from the involved bed is as rapid as that from an uninvolved other bed of the same vessel or the opposite cerebral artery

Trial Study design Device Revascularization rate % of mRS 0–2 at 90 days

MR CLEAN1) Standard of care (IV t-PA for eligible people) vs. Standard of care plus mechanical thrombectomy

59% 32.6% vs. 19.1%

Absolute difference 13.5%

(95% CI, 5.9–21.2%)

ESCAPE14) Standard of care (IV t-PA for eligible people) vs. Standard of care + stent retriever

72% 53% vs. 29.3% p < 0.001

Mortality at 90 days 10.4% vs. 19%

Adjusted rate ratio: 0.5; 95% CI, 0.3–0.8

SWIFT PRIME26) Standard of care (IV t-PA eligibility required) vs. Standard of care (IV t-PA eligibility required) + stent retriever

Solitaire 88% 60% vs. 35%

OR, 1.70; 95% CI, 1.23 to −2.33

EXTEND-IA3) Standard of care (IV t-PA eligibility required) vs. standard of care (IV t-PA eligibility required) plus stent retriever

Solitaire 86% 71% vs. 40%; p = 0.01

REVASCAT21) Standard of care (IV t-PA for eligible people) plus standard of care plus stent retriever

Solitaire 66% 43.7% vs. 28.2%

Adjusted odds ratio, 2.1; 95% CI, 1.1 to −4.0

Hemorrhagic Strokes

Hemorrhagic Stroke• Second most common type of stroke (only 20%)

• Disproportionate high risk of death and long term disability compared to ischemic stroke.

• Aging population + increased anticoagulation for atrial fibrillation has contributed to relative increase in incidence.

• ICH evidence based guidelines are based primarily on multiple clinical trials over the last decade which have shown that patients who present with small ICHs are readily survivable with good medical care.

Hemorrhagic Stroke

Spontaneous non-traumatic bleeding into the parenchyma of the brain.

Common locations

Basal ganglia Thalamus

CerebellumPonsLobar

basal ganglia (40-50%), lobar regions (20-50%), thalamus (10-15%), pons (5-12%) cerebellum (5-10%)

Typical ICH Locations

Pathophysiology

Arterioles or small arteries burst, forming localized hematoma that spreads along white matter pathways

Hypertension

Primary Risk Factor

CT Angiogram: The spot sign

Acute Intervention

• Airway management1. GCS <82. Nausea/vomiting/aspiration

• Blood pressure goals1. 140-160 SBP2. Labetalol bolus 10-20 mg q10 min3. Cardene infusion 5-15 mg/hour

• Coagulopathy1. Anticoagulation/medication history2. Thrombocytopenia history3. Stat labs: PT, INR, PTT, CBC with platelet count4. Anticoagulant reversal

SAH

Symptoms of SAH

• Worst headache of life

• Thunderclap headache

• Neck pain

• Nausea/Vomiting

• Weakness

• Altered mental status

• Photophobia

• Phonophobia

• Cranial nerve palsy

Diagnosis

• CT scan

• Lumbar Puncture

• CTA

• Angiography

RISK FACTORS FOR SAH

• HYPERTENSION

• SMOKING

• ALCOHOL

• SYMPATHOMIMETICS

• PCOS

• CONNECTIVE TISSUE DS

• FAMILY HISTORY

Endovascular

Endovascular Surgery

Pipeline Embolization

Complications of SAH

• Respiratory Failure

• Seizures

• Vasospasm

• Delayed Cerebral Edema

• Cerebral Edema

• Hydrocephalus

• Re-rupture

• Herniation/Death

Early and Late Complications of Stroke

Early Complications (within 7 days)

•Cerebral edema and herniation (within 96 hr)•Expansion of the infarct/recurrent infarction•Hemorrhagic transformation of the infarcted area•Seizure•Aspiration pneumonitis•Gastrointestinal ulcers and/or bleeding•Deep vein thrombosis and pulmonary embolism•Myocardial infarction

Late Complications (>7 days later)

•Recurrent stroke•Seizure•Aspiration pneumonitis•Deep vein thrombosis and pulmonary embolism•Decubitus ulcer•Persistent cognitive or language dysfunction•Persistent loss of mobility•Spasticity

Functional Recovery

• In spite of great advances in acute treatment, many stroke survivors experience debilitating sequelae.1–4

About 800,000 people in the United States have a stroke each year and approximately two-thirds of these require rehabilitation. While evidence-based rehabilitation programs are able to improve functional abilities, the steepest slope of motor recovery occurs within the first 6 months.5 Residual and often disabling long-term deficits are common 6,

7 and frequently due to impaired motor function.8–10

• The modified Rankin score (mRS) is the most widely used as a measure of outcome after acute ischemic stroke (AIS) in both research clinical trials and national and local quality improvement registries.

Post Stroke Care

• Stroke Unit

• PT/OT

• Speech therapy

• Dysphagia screening

• Temperature

management

• Nutrition

• Hypertension

management

• Antiplatelet therapy

• Statin therapy

• Anticoagulation

• Blood glucose

• Rehabilitation

Mechanism of Ischemic STROKE

• Large Vessel

• Lacunar

• Embolic

• Thrombotic

• Artery to Artery

• Dissection

• PFO

• Hypercoagable

• Cryptogenic ESUS

Secondary Stroke Prevention

The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention

EXERCISE

STATIN Therapy

Post Stroke Medications: Anti-platelet

Indications and Duration:

SAMMPRIS vs CHANCE

Plavix

75 mg daily

Interaction CYP2C19 metabolizer

Adverse reactions: bleeding, SJS, pancytopenia, puritis,

Processed through liver, excerpted in urine

Irreversibly binds to P2Y12 adenosine diphosphate receptors, reducing platelet activation and aggregation

No risk for fetal harm

https://www.medicalnewstoday.com/articles/161255.phphttps://www.medicalnewstoday.com/articles/161255.php

Aspirin

81 mg daily or 325 mg daily

Processed by CYP450

Contraindicated: thrombocytopenia, surgery, GI bleeding

Adverse reactions: dyspepsia, N/V, bleeding, diarrhea

Drug interactions: metabolic acidosis, analgesic associated neuropathy

Non-selectively and irreversibly reduces platelet aggregation

BRILINTA/Ticagreloris a potent, direct-acting antithrombotic

agent that binds reversibly to inhibit

platelet adenosine diphosphate P2Y12

receptor.

A systematic review and meta-analysis

of 13 RCTs, comprising 64,360

patients. In comparison to control

group, ticagrelor reduced the risk of IS

,combined ischemic and hemorrhagic

strokes and composite stroke/MI/CVD.

Ticagrelor was not associated with

increased risk of mortality or major

bleeding events. Additional analyses

demonstrated that ticagrelor reduced

the risk of incident strokes and

composite stroke/MI/CVD among

patients with prior history of IS or

transient ischemic attack.

Post stroke Medications: AnticoagulationEliquis

5 mg BID vs 2.5 mg BID

Bleeding risk

Adverse reactions: hematoma, thrombocytopenia, anemia, syncope, nausea

Processed through liver, excepted in urine

12 hour half life

Selectively blocks active sits of factor Xa, inhibiting blood coagulation

Trouble affording medications?

855-Eli-QUIS

https://www.canadianpharmacyworld.com/drug/Eliquis

Primary Prevention

ALL Stroke Risk Factors

Inherent Modifiable

Disease Modifiable Not Modifiable

Ischemic Stroke

•Hypertension•Diabetes

•Atrial fibrillation•Smoking

•Hyperlipidemia•Carotid stenosis

•Lack of physical activity

•Age >55•Male gender•Black race

•Family history of stroke•Personal history of stroke

•Sickle Cell Disease

ICH

•Hypertension•Antithrombotic use•Thrombolytic use

•Coagulopathy•Illicit Drug Use

•Vascular malformation•Amyloid angiopathy

•Neoplasm•Trauma

•Acute ischemic stroke

Subarachnoid Hemorrhage

•Hypertension•Smoking

•Alcohol Abuse

•Aneurysm•Family history of aneurysm or connective tissue disease

•Black or Hispanic Race•Other vascular malformation

•Trauma•Female gender

Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other

vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period

(Class I, Level of Evidence A). Because this benefit extends to persons with and without a history of

hypertension, this recommendation should be considered for all ischemic stroke and TIA patients (Class IIa,

Level of Evidence B).

An absolute target BP level and reduction are uncertain and Sacco et al Guidelines for Prevention of Stroke in

Patients With IS or TIA e411 should be individualized, but benefit has been associated with an average

reduction of 10/5 mm Hg, and normal BP levels have been defined as <120/80 mm Hg by JNC-7 (Class IIa,

Level of Evidence B).

Several lifestyle modifications have been associated with blood pressure reductions and should be included as

part of a comprehensive antihypertensive therapy (Class IIb, Level of Evidence C). The optimal drug regimen

remains uncertain; however, the available data support the use of diuretics and the combination of diuretics and

an ACEI (Class I, Level of Evidence A). The choice of specific drugs and targets should be individualized on the

basis of reviewed data and consideration of specific patient characteristics (eg, extracranial cerebrovascular

occlusive disease, renal impairment, cardiac disease, and diabetes) (Class IIb, Level of Evidence C).

Hypertension

Atrial Fibrillation

AF: Recommendations

1. For patients with valvular AF at high risk for stroke, defined as a CHA2DS2-VASc score of ≥2 and

acceptably low risk for hemorrhagic complications, long-term oral anticoagulant therapy with warfarin at a

target INR of 2.0 to 3.0 is recommended (Class I; Level of Evidence A).

2. For patients with nonvalvular AF, a CHA2DS2-VASc score of ≥2, and acceptably low risk for hemorrhagic

complications, oral anticoagulants are recommended (Class I). Options include warfarin (INR, 2.0 to 3.0) (Level

of Evidence A), dabigatran (Level of Evidence B), apixaban (Level of Evidence B), and rivaroxaban (Level of

Evidence B). The selection of antithrombotic agent should be individualized on the basis of patient risk factors

(particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug

interactions, and other clinical characteristics, including the time that the INR is in therapeutic range for patients

taking warfarin.

3. Active screening for AF in the primary care setting in patients >65 years of age by pulse assessment followed

by ECG as indicated can be useful (Class IIa; Level of Evidence B).

4.For patients with nonvalvular AF and CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic

therapy (Class IIa; Level of Evidence B).

5.For patients with nonvalvular AF, a CHA2DS2-VASc score of 1, and an acceptably low risk for hemorrhagic

complication, no antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered (Class IIb;

Level of Evidence C). The selection of antithrombotic agent should be individualized on the basis of patient risk

factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug

interactions, and other clinical characteristics, including the time that the INR is in the therapeutic range for

patients taking warfarin.

6.Closure of the LAA may be considered for high-risk patients with AF who are deemed unsuitable for

anticoagulation if performed at a center with low rates of periprocedural complications and the patient can

tolerate the risk of at least 45 days of postprocedural anticoagulation (Class IIb; Level of Evidence B).

Large Artery Atherosclerosis

SAMMPRIS Trial

• The Stenting vs Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis

• Demonstrated that “aggressive” intensive medical therapy resulted in better outcomes than stenting among patients with intracranial stenosis

• Dual antiplatelet and Statin therapy

Guidelines for Carotid Stenosis

1. Patients with asymptomatic carotid stenosis should be

prescribed daily aspirin and a statin. Patients should also

be screened for other treatable risk factors for stroke, and

appropriate medical therapies and lifestyle changes

should be instituted (Class I; Level of Evidence C).

2. In patients who are to undergo CEA, aspirin is

recommended perioperatively and postoperatively unless

contraindicated (Class I; Level

of Evidence C).

3. It is reasonable to consider performing CEA in

asymptomatic patients who have >70% stenosis of the

internal carotid artery if the risk of perioperative stroke,

MI, and death is low (<3%). However, its effectiveness

compared with contemporary best medical management

alone is not well established (Class IIa; Level of

Evidence A).

4. It is reasonable to repeat duplex ultrasonography annually

by a qualified technologist in a certified laboratory to

assess the progression or regression of disease and

response to therapeutic interventions in patients with

atherosclerotic stenosis >50% (Class IIa; Level of

Evidence C).

Prophylactic CAS might be considered in highly selected patients with asymptomatic carotid stenosis (minimum,

60% by angiography, 70% by validated Doppler ultrasound), but its effectiveness compared

In addition to addressing the primary reason for the ED visit, the ED encounter may serve to reinforce healthy living, to perform primary disease identification and prevention

-to provide early disease detection (secondary prevention), to encourage and facilitate compliance with disease management

-to refer patients to primary care providers for continued management of existing disease (tertiary prevention) With the growing numbers of Americans using the ED for primary care, especially socioeconomically at-risk populations, the ED may present a unique opportunity to reduce cerebrovascular disease and CVD.

GHS Telestroke Network

The primary goals for Target: Stroke Phase III are:

Achieve door-to-needle times within 60 minutes in 85 percent or more of acute ischemic stroke patients treated with IV thrombolytics.

•Achieve door-to-device times (arrival to first pass with thrombectomy device) within 90 minutes for direct-arriving patients and within 60 minutes for transfer patients in 50 percent or more of acute ischemic stroke patients

treated with endovascular therapy.

Telestroke

22

112

171124

199243 231

307

359

2010 2011 2012 2013 2014 2015 2016 2017 2018

Telestroke Consults Performed

• Prisma Health-Upstate neurologists providing remote emergent telestrokeconsults for all affiliate emergency departments

• Nearly 70% of all emergent consults avoided transfer to GMH by receiving specialist care at the originating site

• Telestroke follow-up consult pilot for non-LVO ischemic stroke patient receiving tPA and admitted at Greer

• Greer Memorial

• 2pm following day

• Neurologist, Hospitalist, RN

• Median neurologist response time of 6 minutes

• Median time to treatment recommendation 10 minutes

Ischemic Stroke Treatment

18.10%

11%

GMH ED - Direct CSC Hospitals

IV Thrombolytic Treatment Rate

25

37

GMH ED - Direct CSC Hospitals

IV Thrombolytic Door-to-Needle Minutes

First line medical therapy for acute ischemic stroke delivered faster and more often than peer group comparison of other Joint Commission certified Comprehensive Stroke Centers.

5.60%

24.10%

13%14.20%

Q1-3 2018 Q4 2018

Mechanical Thrombectomy for Acute Ischemic Stroke Large Vessel

Occlusion

GMH ED - Direct CSC Hospitals

Second line therapy for acute ischemic stroke due to large vessel occlusion delivered at a much higher rate than previously at this hospital and peer group comparison of other TJC CSCs.

Primary Stroke Center Metrics

STK 1 VTE Prophylaxis>90th percentile ranking

98.9%

STK 2 Antithrombotic DC>90th percentile ranking

100%

STK 3 Anticoagulant DC for Afib>90th percentile ranking

99.2%

STK 4 IV tPA Admin>90th percentile ranking

99.2%

STK 5 Antithrombotic D2>90th percentile ranking

98.5%

STK 6 Statin DC>90th percentile ranking

99.7%

STK 8 Stroke Education>50th percentile ranking

95.7%

STK 10 Rehab Plan>90th percentile ranking

100%

Greenville Memorial: Core Metrics

Comprehensive Stroke Center Metrics

CSTK 1 NIHSS Reported>90th percentile ranking

96.4%

CSTK 3a Hunt Hess for SAH>90th percentile ranking

95.9%

CSTK 3b ICH Score>50th percentile ranking

77.8%

CSTK 4 Procoagulant Reversal>90th percentile ranking

100%

CSTK 5 Hemorrhagic Transformation>25th percentile ranking

5.6%

CSTK 6 Nimodipine for SAH>90th percentile ranking

96.7%

CSTK 8 TICI 2b/3 for Thrombectomy>50th percentile ranking

84.6%

CSTK 9 Arrival to Skin PunctureCSC Peer Group (69 min)

62.5 min

CSTK 10 90D mRS ≤ 2CSC Peer Group 39.9%

35.8%

CSTK 11 Arrival to Reperfusion < 120min>75th percentile ranking

76.6%

CSTK 12 Puncture to Reperfusion < 60 min>50th percentile ranking

70.5%

Greenville Memorial Hospital Comprehensive Stroke Center

certified by The Joint Commission

December 2017

Greer Memorial Hospital Successful on-site survey on February 22, 2019

for

Primary Stroke Center

anticipate official certification by April 2019

Recognitions

Oconee Memorial Hospital

Laurens County Hospital

Hillcrest Memorial Hospital

Site level stroke advisory teams and timeline planning for stroke center certification

underway with on-site survey and certification anticipated 2020.

Get With The Guidelines® - Stroke

Gold: 24 consecutive months ≥ 85% in 7 performance achievement metrics

Plus: 24 consecutive months ≥ 75% in 5 of 8 quality metrics

Target Stroke Elite Plus: IV tPA < 60 min 75% & <45 min 50%

Greenville Memorial Hospital &

Greer Memorial Hospital both achieved the highest level of recognition for stroke

care for calendar year 2018 from the American Heart Association/American Stroke Association

Recognitions

Cerebral Angiography

• Diagnostic

• Blood vessel injury due to trauma (BCVI)

• Dissections

• Pseudoaneurysm

• ICAD

• Moya Moya

• Vasculitis

• AVM Embolization

• Aneurysm Embolization

• Dural AV Fistula

• Sinus venous stenosis (IIH/PseudotumorCerebri)

What is next for stroke?

Recent advances in the treatment of acute ischemic stroke, realized by the success of randomized controlled trials of ET, herald novel opportunities to extend such benefit to broader populations of patients with stroke worldwide. Research priorities in ET for LVO stroke are to improve systems of care, investigate effective adjuvant therapies, and explore clinical benefit in insufficiently studied patient population.

Minimally Invasive ICH Evacuation

• Historically no intervention/treatment available for ICH

• Offers clot evacuation via Burr hole using mini scope

• Small incision

• Less recovery time compared to open crani