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Acute Stroke Acute Stroke Rescue and Rescue and
RecoveryRecoveryQaisar A. Shah, MDQaisar A. Shah, MD
Director, Director, NeurointerventionalNeurointerventional and and NeurocriticalNeurocritical carecare
Nancy Arena Nancy Arena GogalGogal, RN, RNManager Manager Cath/EPS/NeuroCath/EPS/Neuro lablab
AMH Stroke Program Evolution
1997:Stroke Program Implemented – Intravenous thrombolyticadministration initiated
1999:Stroke Program Coordinator hired
2004:Received official Primary Stroke Center certificationFirst certified stroke center in Pennsylvania
AMH Stroke Program Evolution
2005:Stroke unit achieved 100% staff training NIH stroke scale
2006:Community education and screening with stroke risk assessment soared Annual Achievement Award for the American Stroke Association 2006, 2007, 2008
2007:Developed a second support group focusing on the different needsof the young stroke patientCommunity Stroke Alert DVD created and distributed
AMH Stroke Program Evolution
Medical emergency team (MET) trained to identify urgent response to stroke
2008:SIM lab for Emergency Trauma Center (ETC) staff for stroke alert education
2009:Stroke alert notification for ETC staff
Introduction of the ServiceIntroduction of the Service
Abington Memorial Hospital is a Joint Commission Abington Memorial Hospital is a Joint Commission certified Primary Stroke Center.certified Primary Stroke Center.
Since the start of Since the start of Neurovascular service Neurovascular service in July 2008, it has in July 2008, it has become a become a ““Comprehensive Stroke CenterComprehensive Stroke Center””
Neurovascular Service consists of;Neurovascular Service consists of;NeurointerventionalNeurointerventional ( 2 ( 2 NeurointerventionalistsNeurointerventionalists) &) &NeurointensiveNeurointensive Care (1 Care (1 NeurointensivistNeurointensivist))
Improvement MeasuresImprovement Measures
Emergency Medical Services (EMS):Emergency Medical Services (EMS):Education/Awareness through series of lecturesEducation/Awareness through series of lecturesMembers of the Stroke committeeMembers of the Stroke committeeModified NIH stroke scale for rapid identification of symptoms oModified NIH stroke scale for rapid identification of symptoms on n the fieldthe field
22 EMS personal are certified in performing NIH stroke scale22 EMS personal are certified in performing NIH stroke scaleEarly notification to the Emergency Department with the NIHSS Early notification to the Emergency Department with the NIHSS Lab draws on the fieldLab draws on the fieldPeripheral intravenous access Peripheral intravenous access Normal saline bolus up to 250 ccNormal saline bolus up to 250 ccDevelop database for constant feedbackDevelop database for constant feedback
Improvement MeasuresImprovement Measures
Emergency Trauma Center (ETC):Emergency Trauma Center (ETC):Education, protocol availability for intravenous and intraEducation, protocol availability for intravenous and intra--arterial arterial thrombolytic therapythrombolytic therapySetup benchmarksSetup benchmarks
Door Door needle time < 60 minutes needle time < 60 minutes Door Door puncture time < 90 minutespuncture time < 90 minutes
Early notification to the;Early notification to the;Radiology (CT scan and the Radiology (CT scan and the NeuroradiologistNeuroradiologist))LabLabPharmacyPharmacy
Stroke committee membersStroke committee members
Improvement MeasuresImprovement Measures
NeuroradiologyNeuroradiology::CTA/CTP for all patients with acute stroke >3 hours using 64 CTA/CTP for all patients with acute stroke >3 hours using 64 slice CT scannerslice CT scanner
CB CBF MTT
Improvement MeasuresImprovement Measures
CathCath lab:lab:
Develop Develop NeuroNeuro cathcath lab team to treat acute stroke lab team to treat acute stroke Stroke alert system Stroke alert system Thrombolytic (Thrombolytic (TenecteplaseTenecteplase) availability in the PYXIS) availability in the PYXISAnesthesia availability Anesthesia availability
NeuroNeuro ICU:ICU:Fully trained ICU staff with focus on dealing with Neurological Fully trained ICU staff with focus on dealing with Neurological emergencies emergencies
NormothermiaNormothermia protocol, hypertonic saline protocol, hypertonic saline Work in progress; LICOX (brain oxygen monitoring device)Work in progress; LICOX (brain oxygen monitoring device)
Improvement Measures
Stroke Unit:Stroke Unit:Fully trained neurological nursesFully trained neurological nursesAll RNs are NIH stroke scale certifiedAll RNs are NIH stroke scale certified
Impact: Case VolumeImpact: Case Volume(Intravenous and Intra(Intravenous and Intra--arterial treatments)arterial treatments)
Impact: Rapid Evaluation and RxImpact: Rapid Evaluation and Rx
Prospective DatabaseProspective Database
Total of 28 patients were taken to the Total of 28 patients were taken to the cathcath lab for Intralab for Intra--arterial treatment of Stroke between July 2008 arterial treatment of Stroke between July 2008 –– August August 20092009
All patients underwent CTA/CTP at baselineAll patients underwent CTA/CTP at baselinePatients with normal head CT and with no mismatch were Patients with normal head CT and with no mismatch were not treated with further intervention not treated with further intervention
21/28 patients underwent intra21/28 patients underwent intra--arterial treatment (seven arterial treatment (seven patients had no arterial occlusion)patients had no arterial occlusion)
Prospective DatabaseProspective Database
Neurological improvement Neurological improvement was considered if there was was considered if there was ≥≥4 points decrease in 4 points decrease in NIHSS within 24 hoursNIHSS within 24 hours
Favorable outcome Favorable outcome was measured as modified Rankin Scale (was measured as modified Rankin Scale (mRSmRS) of ) of ≤≤ 2 at 3 2 at 3 monthsmonths
Symptomatic Symptomatic IntracerebralIntracerebral Hemorrhage Hemorrhage was considered when there was ICH with was considered when there was ICH with worsening of neurological symptoms within first 24 hours (NIHSS worsening of neurological symptoms within first 24 hours (NIHSS ≥≥ 4 points)4 points)
6.4% after IV 6.4% after IV tPAtPA77--10% after IA 10% after IA tPAtPA
Rate of Rate of RecanalizationRecanalization, TIMI grading scale was used , TIMI grading scale was used TIMI grade 0 = no flowTIMI grade 0 = no flowTIMI grade I = partial TIMI grade I = partial recanalizationrecanalization with no distal flowwith no distal flowTIMI grade II = partial TIMI grade II = partial recanalizationrecanalization with good distal flowwith good distal flowTIMI grade III = complete TIMI grade III = complete recanalizationrecanalization
Age Gender
Procedure Baseline NIHSS
24 hr NIHSS
Symp ICH AsympICH
3 month mRS
67 M TNK 14 8 - Yes 088 M TNK, CAS 20 11 - - 479 F TNK, MERCI,
Balloon18 42 Yes - 6
73 M TNK, ICAD stent, CAS
24 4 - - 1
59 M TNK 12 4 - - 153 F TNK 21 21 - - 363 M ICAD Stent 6 0 - - 0
59 M TNK 16 6 - - 069 M TNK, Penumbra 22 13 - - 1
81 M Penumbra, CAS 22 22 - Yes 4
58 M TNK, ICAD stent
22 22 - - 4
88 F TNK, Penumbra 25 12 - - 3
Age Gender Procedure Baseline NIHSS
24 hr NIHSS
Symptomatic ICH
Asymptomatic ICH
3 month mRS
48 M TNK, angioplasty
18 3 - Yes 0
88 M TNK, Penumbra
18 8 - - 1
84 F CAS 11 0 - - 0
82 F TNK 22 22 - - 6
76 F TNK 7 5 - - 0
76 M MERCI 24 15 - - 3
37 M TNK 21 4 - - 0
59 M CAS 14 12 - - 3
66 F TNK 6 4 - - 0
ProceduresProcedures
Procedure No.
Tenecteplase alone 8
Tenecteplase + Mechanical Thrombectomy 8
Mechanical Thrombectomy alone 5
MechanismMechanism
Mechanism No. (%)
Cardioembolic 14 (62%)
Atherosclerotic 6 (28.5%)
Arterial Dissection 2 (9%)
ResultsResults
Median Age (years) 69
Median NIHSS 18
Neurological Improvement (%) 67%
Recanalization (%) 90%
Favorable outcome (%)mRS
57%
Symptomatic ICH (%) 4.7%
Asymp ICH (%) 14%
Mortality (%) 9.5%
AchievementsAchievements
Because of rapid growth of the program we were able to Because of rapid growth of the program we were able to recruit more staffrecruit more staff
Started Started ““ABINGTON ANNALSABINGTON ANNALS”” which is a scientific which is a scientific institutional journalinstitutional journal
Annual Neurovascular ConferenceAnnual Neurovascular Conference
Weekly stroke rounds, and monthly Neurovascular roundsWeekly stroke rounds, and monthly Neurovascular rounds
Develop partnership with neighboring hospitals and Develop partnership with neighboring hospitals and provide expedited transfers to Abington Memorial provide expedited transfers to Abington Memorial Hospital for comprehensive careHospital for comprehensive care