Acute Stroke Acute Stroke Rescue and Rescue and Recovery Recovery

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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

    Acute Stroke Rescue and RecoveryAMH Stroke Program EvolutionAMH Stroke Program EvolutionAMH Stroke Program EvolutionIntroduction of the ServiceImprovement MeasuresImprovement MeasuresImprovement MeasuresImprovement MeasuresImprovement MeasuresImpact: Case Volume (Intravenous and Intra-arterial treatments)Impact: Rapid Evaluation and RxProspective DatabaseProspective DatabaseProceduresMechanismResultsAchievements