THE B.E.S.T. TREATMENT OF ACUTE ISCHEMIC STROKE...Implement best practices in the treatment of acute...

11/21/2016

1

Miami Neuro Symposium 2016

THE B.E.S.T. TREATMENT OF

ACUTE ISCHEMIC STROKE

Dr. Felipe de los Rios

Medical DirectorStroke Program – Baptist Health South FloridaComprehensive Stroke Center - Baptist Hospital of Miami

Conflict of Interests

� None.

Objectives

� Understand the therapies available for the treatment of acute ischemic stroke

� Identify which patients are eligible for intravenous IV tPA and/or endovascular reperfusion therapies

� Implement best practices in the treatment of acute ischemic stroke

11/21/2016

2

Outline

� Epidemiology

� IV thrombolysis

� Which patients benefit

� Who is at increased risk of complications

� How to manage post rtPA hemorrhagic conversion

� Endovascular treatment

� Which patients benefit

� Overview of treatment impact

� BEST practices

Stroke

� Prevalence is estimated at 6.6 million Americans ≥ 20 years old

� Incidence is estimated at 795,000 people every year

� 1 in 6 men will have a stroke during their lifetime

� 1 in 5 women will have a stroke during their lifetime

� Worldwide it is the 2nd cause of death and disability

� 67% of all ischemic strokes occur in LMIC´s

Mozaffarian D, Circulation 2015.

87%

10%3%

87% of all stroke is ischemic

Ischemic

Hemorragic

Sub-arachnoid

GCNKSS, NINDS, 1999

11/21/2016

3

IV Thrombolysis

Hypothetical representation of 16 patients treated with t-PA vs 16 patients treated with placebo based on NINDS results at 3 months.

Placebo

T-PA

11/21/2016

4

Low recanalization rates with proximal occlusions

Tomsick et al (2010) Neurology

Logistic regression curve representing an estimate of the probability for successful recanalization of occluded vessels by intravenous thrombolysis (IVT) depending on thrombus

length.

Riedel C H et al. Stroke. 2011;42:1775-1777

Figure 1. Sonographic pattern of clot lysis during tPA infusion among stroke subtypes.

Molina CA, Stroke 2004.

11/21/2016

5

Increase the risk of hemorrhagic conversion

� Size of ischemia

� Advanced patient age

� Prior use of anticoagulants or aspirin

� History of heart failure

� Elevated BP

� Presence of microbleeds by MRI (GRE sequence).

� Endocarditis (symptomatic transformation risk 20% vs 6.5%)

Time is brain

Hacke, Lancet, 2004

11/21/2016

6

Required tests

� Non contrasted head ct scan

� Serum glucose

� Oxygen saturation

� CBC, including platelet count

� Creatinine, BUN

� Electrolytes

� Coagulation profile: PT, PTT, INR

� ECG

� Markers of cardiac ischemia

Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA / ASA Stroke. 2013

HCT scan and glucose is enough if:

� No use of anticoagulants

� No active cancer

� No renal or liver disease

� No alcohol or drug abuse

� No suspicion for coagulopathy or thrombocytopenia


Who qualifies?

� Inclusion criteria

� Diagnosis of ischemic stroke causing measurable neurological deficit

� Onset of symptoms <4.5 h before treatment initiation

� Age ≥18 years old


11/21/2016

7

Minor stroke & rapidly improving

� Discharge outcomes

� 27% not discharged home

� 27.2% did not ambulate independently

� Significant component of cognitive dysfunction, fatigue, depression.

� Higher risk of deterioration:

� Higher initial stroke severity and visible arterial occlusion

� Risk of hemorrhagic transformation is lower (0-2%)

Romano JG, et al. Stroke, 2016.


Rapidly improving Stroke Symptoms as an exclusion criteria

� Improvement to a mild stroke such that any remaining deficits seem non-disabling

� Any of the following typically should be considered disabling deficits:

� Complete hemianopsia (≥2 on NIHSS question 3)

� severe aphasia (≥2 on NIHSS question 9)

� Visual or sensory extinction (≥1 on NIHSS question 11)

� Any weakness limiting sustained effort against gravity (≥2 on NIHSS question 6 or 7)

� Any deficits that lead to a total NIHSS score >5

� Any remaining deficit considered potentially disabling in the view of the patient and the treating practitioner. Clinical judgment is required.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. AHA / ASA. Stroke 2016

Be careful with patients who have:

� Fever

� Hypotension:

� Sepsis, shock

� Endocarditis

� Aortic dissection (chest pain, asymmetric pulses, widened mediastinum)

� Severe headache

� Bleeding

� Migraine

� HaNDL

� reversible cerebral vasoconstriction syndrome

� Sinus vein thrombosis

11/21/2016

8

Reversal of hemorrhagic transformation (within 24 hours)

� Stop rtPA infusion

� Cryoprecipitate 10 units initial dose

� If cryoprecipitate not available, then either

� Tranexamic acid 10-15 mg/kd IV over 20 minutes

� E- aminocaproic acid 4-5 g IV

� Check fibrinogen levels after treatment administration. If < 150 mg/dl then administer more cryoprecipitate

� Unclear if platelet transfusion is useful

� Consider neurosurgical consultation

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage. Neurocritical care Society. Neurocritical Care, 2016.

https://en.wikipedia.org/w/index.php?curid=31837346

Endovascular Treatment

11/21/2016

9

Serrone JC, Neurosurgery 2013.

Mokin M, Neurosurg Clin N Am 2014.

Who qualifies?

� Prestroke mRS score 0 to 1

� Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies

� Causative occlusion of the ICA or proximal MCA (M1)

� Age ≥18 years

� NIHSS score of ≥6

� ASPECTS of ≥6, and

� Treatment can be initiated (groin puncture) within 6 hours of symptom onset

Powers WJ. 2015 AHA / ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke, 2015.

11/21/2016

10

Modified Ranking Scale (MRS)

ASPECTS Score

www.aspectsinstroke.com

Positive trials

� MR CLEAN (2015)

� ESCAPE (2015)

� SWIFT PRIME (2015)

� EXTEND – IA (2015)

� REVASCAT (2015)

11/21/2016

11

Benefit up to 7.3 hours?

Saver JL. Time to Treatment With Endovascular Thrombectomyand Outcomes From Ischemic Stroke: A Meta-analysis. JAMA

2016

MR CLEAN

� Design: Open label, multicenter, RCT with blinded end-point evaluation between 2010 and 2014.

� Patients: 502 patients

� NIHSS ≥ 2

� ≥ 18 years old

� AIS + anterior circulation LVO (ICA, M1, M2, A1, A2)

� Initiation of IA treatment < 6 hours of sx onset

� Intervention:

� IA (thrombolytic +/- mechanical) + usual care: N=233

� Retrievable stents used in 81.5%

� IV tPA in 87.1%

� Usual care: N=267

� IV tPA in 90.6%

MR CLEAN Investigators. NEJM, 2014.

MR CLEAN

� Main outcome measures: ITT

� Primary: 90 day mRs

� Secondary: 24 Hr NIHSS, discharge NIHSS, 90 day Barthel index, 90 day EuroQoL5D

� Results:

� Patient characteristics:

� Mean age 65 yo (23 – 96)

� Men 58.4%

� Median NIHSS (IQR): Intervention 17 (14-21). Control 18 (14-22)

� Aspects (IQR): Intervention 8 (7-10). Control 9 (8-10)

� Time in minutes from stroke onset to randomization (IQR): Intervention 204 (152-251). Control 196 (149-266)

� Time in minutes from stroke onset to groin puncture (IQR): Intervention 260 (210-313)


11/21/2016

12

MR CLEAN

� Primary [90 day mRs]: Intervention 3 vs. Control 4 (OR 1.66; CI 1.21 – 2.3).

� mRs 0-2 at 90 days: Intervention 76% vs. Control 51% (OR 2.16; CI 1.39-3.38)

� Recanalization rate (24 hr CTA): 75.4% Intervention vs. 32.9% Control (OR 6.88; CI 4.34 – 10.94)

� Symptomatic ICH: 18% Intervention vs. 17% Control.

� New symptomatic AIS in different vascular territory: Intervention 5.6% vs. Control 0.4%


Limitations

� Costs:

� IV tPA: $ 6,749

� Endovascular therapy: $ 24,154

� Little evidence of benefit > 6 hours

� Little evidence of benefit for mild to moderate strokes

� No evidence in pediatric population

� ICH risk is unchanged compared to IV tPA

� Infrastructure and resource requirement

� Benefit is time dependent

Chen M. Neurology, 2012.

Baptist Emergency Stroke Team

11/21/2016

13

TRIM II

Team

ED MD & RNs

BEST RN

Neurologist

NeuroSurgeon

NeuroInterventio

n MD & RNs

AnesthesiaMD

Neuro RN &

Research Team

Registration

Lab

Neuro Radiologist & Imaging

Pharmacist

PI RNs & Center of

Excellence

Care Mgmt.

TransferCenter

Risk Mgmt.

Time is Brain!

Multidisciplinary

Team

40 Participants

B.E.S.T. approach

� EMS pre-notification

� Emergency registration of NNs

� Single activation stroke alert system

� Dedicated ER rooms for stroke alerts

� No need to duplicate fingerstick glucose or ecg

� Streamlined arrival to CT protocol

� Streamlined bloodwork and radiology

� No paper consent for IV tPA or NIVR

� Telestroke

� BEST nurse team

11/21/2016

14

Conclusions

� Both IV-tPA and endovascular therapies are effective treatments for acute ischemic stroke.

� Consider IV-tPA in all acute ischemic stroke patients within 4.5 hrs of last seen normal

� Consider endovascular treatment in all acute ischemic stroke patients within 6 hrs of last seen normal

� A multidisciplinary team that works together and meets frequently will improve institutional acute stroke care

Thank you!

Quebrada Santa Cruz – Punta Union, Huaraz, Peru. 4750 M.A.S.L.

Baptist Hospital of Miami

THE B.E.S.T. TREATMENT OF ACUTE ISCHEMIC STROKE...Implement best practices in the treatment of acute...

Documents

Transcript of THE B.E.S.T. TREATMENT OF ACUTE ISCHEMIC STROKE...Implement best practices in the treatment of acute...