Implementing pathway for Neuro-intervention in

Hyper acute Stroke for Clinical and Research

Dr. Indira NatarajanConsultant Stroke Physician

Clinical Lead for Acute Stroke TIA ServicesUniversity Hospital of North StaffordshireClinical Lead for Stroke – Heart and Stroke

NetworkShrosphire and Staffordshire

UK National Stroke Strategy

There may be a role for interventional neuroradiology in the management of basilar thrombosis. Patients should have access to a stroke service with neuro-interventional capacity.

A network approach may be required to develop an agreed protocol, so that each stroke unit is linked to a regional neurosciences centre for emergency review of local brain imaging- for example by electronic link- and emergency transport (and then repatriation) of appropriate patients.

Strategic Health Authorities, through specialised commissioning arrangements, to support the co-ordination of the availability of specialist neuro-intensivist care including interventional neuroradiology and neurosurgery expertise….

DH National Stroke Strategy 2007, page 32.

BASP CS views

There is a need for RCTs of endovascular treatments and UK stroke services should recruit patients to such trials once they are open.

Endovascular treatments should not be offered routinely until evidence from RCTs is available

Until such evidence is available treatment should be on a case by case basis guided by agreed treatment and referral pathways

EVT should only be given in centres with agreed pathways and protocols including A&E, the stroke service, neuro-interventionalist, ITU and speciality nurses

Participation in national register/ International registers

Centres participating in RCTs will have to have experience in the procedure before enrolling patients.

UHNS Acute Stroke Unit (ASU) 2001 to 2010 Outcome/Results

0%

10%

20%30%

40%

50%

60%

70%80%

90%

100%

Death

Ongoing Care

Home

Integrated working 32 Beds

39 Beds24 Beds

Where are we?

Regional Thrombolysis rota for 24/ 7 cover across the region

( Feb 2011)

Telemedicine ( April 2012)

Until 2010 No clear Neuro- interventional pathway

December 2009 75 year old gentleman Recent cervical spine surgery 4 months ago Admitted with collapse and found unconscious GCS 4/15 Intubated and ventilated No reversible pathology Atrial fibrillation CT brain Normal study

First encounter……..

Cervical Halo

Discussion with Orthopaedic Surgeon/ Neuro-radiologist

Agreed for Intravenous and intra-arterial Anaesthetist arranged Whole episode was chaotic Since no clear pathway - theatre team difficult to co-

ordinate ODA had to be pulled off from Neuro-surgical theatre Significant amount of time lost from arrival of patient

to A and E and before procedure commenced

Basilar occlusion on CTA

Time is Brain……

Pathway for ischaemic stroke treated with r t-PA?

999

Triaged in A and E

Within 3 - 4.5 Hrs

Neuro-interventional pathway

999

Time is Brain

The Team

1 Radigrapher1 Nurse

Anaesthetist / ODA

Stroke Physician

Interventional Neurorradiologist

Age<75 Previously fit and well Working hours (out of hours if interventional

neuroradiologist available)  

Agreed patient group…

Radiology / Neuroradiology Anaesthetics/ ITU Neurosurgery Emergency Medicine

Teams that we engaged

Yellow sheet for Stroke patients CT brain and CT angiogram as agreed

protocol

Radiology protocol

CT head scan

Order a non-contrast CT head immediately after arrival (urgent e.g. within 1 hour) for all strokes.

[label form ACUTE STROKE call 4042 (daytime) or on call radiologist (nights, weekends and holidays)].

Thrombolysis candidates and patients on warfarin must be scanned immediately (within 15 min)

Order a CT angiogram (arch to Circle of Willis) if <75 y and no

contraindications to contrast and within < 8 h of onset and no haemorrhage and no signs of established

infarction on the CT head scan.

Neuro-radiologist / Stroke Physician alerted when

CT angiogram findings which suggests need for IA intervention

Carotid T occlusion (intracranial carotid bifurcation occlusion with involvement of A1 and M1 segments)

M1 (trunk of the MCA) or M2 (MCA branch in Sylvian fissure) occlusion

Vertebro- basilar thrombosis

Emergency theatres prioritisation codes

E1 Immediate transfer to theatre E2 Within 6 hours E3 Within 12 hours E4 Urgent, but timing not critical 

To get a Standard Operation Pathway

agreed for Stroke as E 1

Potential indications for EVT

Primary intra-arterial thrombolysis Severe disabling neurological deficit and Contraindications to iv thrombolysis (e.g. recent surgery), 3-6 h from symptom onset

Intravenous/ Intra-arterial /EVTSevere disabling neurological deficit and Large vessel occlusion in MCA

Brain stem strokeTreatment can be delivered within 9 h of symptom onset and Occlusion of basilar artery documented on 4-vessel angiography Eligible even if consciousness impaired and or patient ventilated

Consent Sheets form 1 / form 4 Patient information sheet Theatre check list IA log Nursing pathway for Intervention

Key paperworks……

Time CT angio  

IV alteplase given Y / N

Time of IV alteplase bolus  

Consent/assent signed Y / N

Time of last micturition(offer bottle & conveen)

 

Arrival time in cathlab  

Anaesthesia GA / LA

Start time of GA/LA  

Time of femoral puncture = start of procedure

 

Start time catheter angio  

Catheter used for angio  

IA lysis done Y / N

Catheter used for IA lysis  

Time of IA catheter at clot  

Time first dose of IA tPA  

Time last dose of IA tPA  

Total dose of IA tPA  

Total dose of IV & IA tPA  

Mechanical Thrombectomy Y / N

Device used for MT  

Stat time of MT  

No of attempts of MT  

Time of clot capture  

Time of final catheter angio = end of procedure

 

Time of post procedure CT (after final angio)  

Time out of cathlab  

Arrival time in stroke unit  

Potential patient for IAT/MT identified Fit for GA/ thrombectomy Previously independent NIHSS>=10 or basilar artery thrombus No bleed or sub acute infarct on CT head CTA shows large vessel occlusion (ICA/M1/M2/

VA/BA/ PCA)    

Suitable patient

Start iv lysis while waiting for theatre. Give 0.6 mg /kg alteplase (bolus and infusion) iv unless iv lysis is contraindicated (recent surgery, post-partum). Leave 0.3mg/kg (max 30 mg) for i.a. lysis.

Do CT head immediately post procedure and after 24 h. Stay with patient until awake and settled on stroke unit. Ensure patients is monitored according to the IAT nurse

pathway.        

Lysis Protocol

Pathway in action…. Keep next of kin on site for consent /queries or establish contact

route  Clinician (stroke physician / A&E doctor) to get an anaesthetist

STAT: neuro-anaesthetist, if possible, otherwise on call: contact via switch

 Clinician (Stroke physician / A&E doctor) to inform ODA  Out of hours Arrange for an anaesthetist – go to online services /

rota watch / on call anaesthetist – bleep 3rd on call  Radiologist to get radiographer and scrub nurse for the

procedure. Set up operating trolley and equipment immediately. Inform Stroke Unit for arranging a bed – Stroke team

(A&E staff/ stroke team/ neurointerventionalist) Discuss procedure Complete consent form Complete theatre checklist (inside the consent

form) Put patient into a theatre gown Offer bottle or catheterize Put in IA line (in A&E or theatre) Transfer to neuro-interventnional theatre

Prepare the patient

Start the intra-arterial intervention log Theatre team to move patient onto the intervention table Theatre team to cover patient with sterile sheets Anaesthetist and ODA to commence local/ general anaesthesia Neuroradiologist or scrub nurse to clean/ disinfect groin.

Prepare for intervention

Complete intra-arterial intervention log Remove catheter/ intra-arterial line Liaise with ASU to alert team about patient transferGet a bed tracked to the intervention suite to transfer patient to ASU Patients who were ventilated before the procedure may need ITU/MIU.

During / After Intervention

Devised protocols through our Heart and Stroke Network for regional DGH’s

Clear pathway for in hours and out of hours Drip and Ship with escort We have accepted patients outside our

region on occasions

Regional referral protocols….

Trust

Commissioning

Costing

Getting all the teams together

Barriers…..

Media – Not a good idea

Pioneering stroke drugs saved PatientThis is Staffordshire

FATHER-OF-FOUR owes his life to being at the right place at the right time after suffering a massive stroke

.The attack was severe enough to give him just a 20 per cent chance of surviving.

•

Tuesday, February 09, 2010

Consumables overall                   £ 1600 Device cost ranges roughly around      £ 4000 ( prices can be negotiated depending upon trusts) Average use of devices is around 1.5 (from our

experience of 50 cases) Out of hours theatre staff cost             £  500 ---------------------------------------------------------------------------------

------------ Overall rough cost estimate is around   £ 6100  

Costings……

Hospital Care Basic bed day in Stroke unit: £ 170 /day With added costs : £ 350/ day Patients with mRs 4 and 5 average LoS: 90 days Cost for 90 days: £ 31,500

Social / Residential care: mRS 5 : £550 / week ( £ 28,600/ year) mRS 4: £ 400 - £ 450 /week ( £ 20,800 - £ 23,400/year) mRs 3: ( if care required) : £ 300/week ( £ 15,600/year)

Cost for Post Stroke Care

Funding

Primary Care Trust 2NHS 2Stroke Network 1Stroke Fund 1Intervention Fund 1Neuroscience Department 1Geriatric Medicine 1Under discussion 1

Percutaneous trans-luminal embolectomy / thrombectomy of artery:

L 712 HRG - QZ15 A - Major complication with co-

morbidities £ 9554 HRG – Q Z15B – Minor complications £ 5098 HRG – QZ15 C – No complications £3731   On top for Alteplase: you get another 800£

HRG Coding

24/ 7 Sustainability Reliant on key individuals Job Plan Integrated pathway agreement with other

centres Need to demonstrate quality before taking

part in Research trials

Challenges

Centres in the UK

> 1 per month 5 – 10 / 10 months

Frequency of endovascular treatments for acute ischaemic stroke in active centres in 2010

Number of centres

0 4

1-4(1 every 3 mo or less)

8

5-9(one every other month)

5

>=10 6

Capacity, organisation, and quality control ( Nationally)

23 active centres

71 interventional Neuroradiologists in the UK in 2010

46% of centres not providing EVT had no procedures for referral to centres providing such treatments.

56% of centres providing EVT entered patients into the SITS register

56% of centres providing EVT entered patients into the SINAP

Type of Approach

Thrombolysis pathway Neuro-interventional pathway

Newer interventions needs newer pathway Part of expansion of Neurosciences Units Part of the Clinical Research activity

One needs to start somewhere………………..

In Summary

http://www.stroke-in-stoke.info/

You can look at our: Pathway Patient Information leaflet Procedure log Nurse pathway Protocols Data entry file – We are happy to support data

Resources

Prof Christine Roffe Dr. Sanjeev Nayak All the Neuro-interventional team /

Anaesthetic team/ ITU team / Stroke team/ Exec Board

Acknowledgements….