2016: national acute stroke protocol standard of care and emerging technology-osborne
TRANSCRIPT
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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
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Financial Disclosure
I do not have direct or indirect financial interest in the equipment or medications
discussed in this lecture
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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Patient Presentation
• Provided History: • Patient with AMS ? CVA
• What do you do next?
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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?
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Reference: www.strokeassociation.orgwww.strokeassociation.org/STROKEORG/Professionals/TargetStroke/Clinical-Resources-and-Tools_UCM_432411_Article.jsp#.WDqqbTHrucm
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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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
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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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
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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
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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
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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.
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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.
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Core
Penumbra
Thomas Osborne, MD
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/terms
6. Prehospital EvaluationThomas Osborne, MD
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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)
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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.
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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
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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?
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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)
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http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
http://stroke.ahajournals.org/content/44/3/870
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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.
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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
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CT Exclusion criteria for tPA
ECASS I, NINDS
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Following 3 slides:Best practice quick references
with links
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Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/heart-public/@wcm/@gwtg/documents/downloadable/ucm_470145.pdf
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Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/stroke-public/@private/@wcm/@hcm/@gwtg/documents/downloadable/ucm_431633.pdf
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Reference: www.strokeassociation.orghttp://www.strokeassociation.org/idc/groups/heart-public/@wcm/@gwtg/documents/downloadable/ucm_470723.pdf
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Stroke Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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Additional Diagnostic OptionsThese should not delay Rx with IV rtPA
• CTA (need for IA Rx) • MRI• Perfusion (MRI or CT)
Thomas Osborne, MD
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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
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Stroke Perfusion Imaging
Moving from a time to a physiology paradigm
Thomas Osborne, MD
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R2* = -ln s (baseline)
s (t)
TE
{ }AUC = CBV
Deconvolution
AIF
CBFCBV
MTT =
SI curve to Concentration curve
Peak = CBF
Residue Function
SI
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larrylakey.com
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Core
Penumbra
Thomas Osborne, MD
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Basic PathophysiologyCore-Penumbra
Maximal Vasodilation
Acute Ischemic Stroke. Gonzalez et al. 2006 Thomas Osborne, MD
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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
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Perfusion Physiology
1
Thomas Osborne, MD
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Perfusion Physiology
2
Thomas Osborne, MD
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Perfusion Physiology
3
Thomas Osborne, MD
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Perfusion Physiology
4
Thomas Osborne, MD
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Thomas Osborne, MD
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What you are looking for?DWI vs MTT mismatch
(DWI vs. NIH Stroke Scale mismatch)
DWI ADC MTT
Vs
Thomas Osborne, MD
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CBV TTP
CBF MTT Delayed
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Lecture Outline
1. Patient Presentation
2. Stroke Stats
3. Pathophysiology
4. Rx / National Stroke Protocol
5. Advanced Technology/Terms
6. Prehospital EvaluationThomas Osborne, MD
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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
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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
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Thomas Osborne, MD