Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon

How to reduce time between patient arrival and puncture-

Hospital flow and protocol

MR CLEAN TrialNetherlands, 2015

ESCAPE TrialCanadian, 2015

EXTEND-IA TrialAustralian, 2015

SWIFT PRIME TrialUSA, 2015

REVASCAT TrialSpanish, 2015

The most significant factor that can influence positive outcomes is development of a multidisciplinary stroke team and a high level of communication between the emergency room, the neurointerventional team, and the neurology team, along with a concurrent rapid, highly efficient, protocol-based approach to acute stroke management.

•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.

Every 30-min delay in angiographic reperfusion reduced the relative likelihood of a good clinical outcome by 12% in adjusted analysis.

For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%.

Beating the Bullet!!!!

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

Onset to groin/reperfusion time

In IMS III, the endovascular arm had a mean onset-to-groin puncture time of 208 minutes and onset to reperfusion was 325 min.

MR RESCUE trial, the mean time from imaging to groin puncture alone was 124 minutes.

Onset to door time-- Hurdles

The worst clinical outcomes were noted with door-to-puncture times of 136 minutes or greater

( J Am Heart Assoc. 2014;3:e000859

N=478

• 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

One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed.

In the pre-QI cohort (ie, sequential process), the greatest delay occurred from imaging to the neurointerventional (NI) suite (“picture-suite”: median, 62 minutes; interquartile range [IQR], 40 to 82). The post-QI (ie, parallel process) median picture-to-suite time was 29 minutes (IQR, 21 to 41; P<0.0001).

P2P Challenges

• CT vs MRI

• Availability of the angiosuite SOS

• 24x 7 neurointerventionist, anaesthetist, technician, nurse

• Team of like minded people

• Overcoming the Financial Barrier

Imaging…

• CT vs MRI • CT & CTA is the standard • In previous institution – CTP • In current – MRI DW• However, we should have Indian

guideline – CT , CTA. Training of radiologists and neurologists in interpretation

Stroke protocol

Lab..

ANGIO SUITE•Biplane lab• Aneurysm, AVM, CAS•Close –co-operation with cardiologist •Lab near the radiology

Services…• 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 team• Based on group practice • One fellow – Stroke-INR fellowship

Technician•Encouraged to stay nearby •Training program

Anesthesia and critical care •NI program is part of clinical neurosciences•Active – neurovascular program – SAH•Neuroanesthesia provide cover as for HI etc hn

Financial barrier•Most 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 pictures•Detailed counseling everyday on written form

Promoting stroke intervention program – In hospital

• Buy-in from fellow neurology and neurosurgery – group practice model

• Hospital admin – all acute neurological emergency , branding

• Common protocol• Protocol presentation and training – neurology,

neurosurgery, emergency, radiology, neurocritical care, all other critical care

• Testimonials • Monitor the results

Promoting stroke intervention program – outside hospital

• Stroke training program for physicians• Encouraged to take opinions • Neurology services to selected centers • Public lectures – Rotary, Lion clubs• Stroke week • Media

Rapid Triage Protocol and Stroke Team Notification

Single Call Activation System

Changes at our hospital

Door time recording by CCTV footage

Door to CT• No dress change

• No valuable transfer

• No consent for CT

• 18 gauge cannula

Transfer Directly to CT

Rapid Acquisition and Interpretation of Brain Imaging

Multimodal imaging protocol (CTA/CTP)

Changes …

•

Parallel approach

Clinical assessment ‘en route’ to Imaging.Access line and blood investigations (POC)Prepare IV tPAAlert Angio suite/ Lab personnelFinancial considerations/ undertakingConsent – pre written

Changes …

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)30 minutes reduction

• Puncture to reperfusion

• POST Median 42 minutes (12 – 120)

Case

• 60 year old man• History of sudden onset weakness on right

side at 6:30 AM• Arrived in emergency at 8:05AM (95 min)• Global aphasia• NIHSS 16 • Known case of mitral valve replacement• On Acitrom

8:22 AM (17 min)8:27AM (22 min)

8:31AM ( 26 min)

Patient on acitrom

INR came (8:45 AM)-2.6

IV tpa ruled out

9:10 AM(65 min) 9:22 AM 9:27 AM( 77 Min)

Door to recanalization time< 90 minImaging to recanlization time< 60 minComplete recovery

Hospital Layout

TRIAGE

CT Room

DSA Room

Ground Floor

Third Floor

There was a significant difference between groups for door-to-reperfusion timing,favoring patients admitted during normal business hours (146 versus 165 min, p = 0.02).

CT to groin puncture was 127 minutes (n=341; IQR 51 minutes) compared with 142 minutes during nighttime (n=63;IQR 60 minutes; P=0.0012)

Centers performing more than 50 endovascular intra-arterial stroke interventions annually were designated as HV centers.

Patients treated at HV centers were more likely to have a good clinicaloutcome (OR 1.86, 95% CI 1.11 to 3.10, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008)

Puncture to Recanlization time

• Planning on CT angiography

• Local anaesthesia

• No groin preparation

• Putting Foley’s after deploying stent

• Standardized stroke kit that is ready to go

• Use of balloon guide catheter

• Push & Fluff technique

(Stroke. 2014;45:e252-e256.)

Conclusion

• Improving door to puncture time may be the key

SNIS – 2015 …

• Target Door to puncture < 60 min

Door to recanalization <90 min

• Small steps make a big difference!!!

Thank you ….