ED Stroke Update

DAVID BLACKER

Neurologist & stroke

physician,

Sir Charles Gairdner

Hospital

Clinical Professor of

Neurology

University of WA

Medical Director

WA Neuroscience Research

InstituteNo disclosures

?Best Rx for large clots

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

Copyright © American Heart Association

Solitaire FR Stentriever

possibly the preferred option

Basilar thrombosis- SCGH case

Very early thrombectomy combined with intravenous

tPA for acute ischaemic stroke; the Sir Charles

Gairdner Hospital (SCGH) experienceSSA 2011 Blacker DJ, Phatouros C, Singh TJ, McAuliffe W, Bynevelt M, Triplett J, Bukhari W,

Musuka T

Recent transfer to SCGH Initially registrar to registrar contact

Wrong hospital

NOT a stroke

Distress to patient

Delays on return

$$$$$$

How do we do better?

Is transfer required For stroke?

For neurological evaluation

Who is to benefit from the transfer?

Patient?

Family?

Doctors?

Stroke Units In Utopia

All patients should be managed in a stroke unit, since

the evidence suggests better outcomes.

Stroke UnitsStroke Unit benefits

Benefit 5.6/100

reduced mortality (22% v 26%)

reduced dependency (56% v 62%)

reduced cost of care ($10-16 000 savings)

LOS reduced 2-11 days

Stroke UnitsStroke unit features

geographically distinct

comprehensive assessment

co-ordinated MDT

early mobilisation (avoid bed rest)

staff with interest; ongoing training and education

team meetings (DC planning)

encourage patient participation in rehab

Stroke UnitsReasons for benefit

application of proven treatments

?more intense monitoring of physiology

anticipation, early recognition, and treatment of complications

volume of practice

audit, review, QA, research

enthusiastic, expert staff

Stroke Unit- Physician role Knowledge of stroke and TIA

Accurate determination of mechanism

Institution of appropriate Rx;

eg anti-coagulation for AF

CEA -symptomatic high grade stenosis

Correct Dx of mimics

Patients to transfer to teritary or

“quaternary” centres

1. Acute therapy for ischaemic stroke; depends on system of care

2. Most cases of ICH (if active treatment planned)

3. Young massive MCA, candidates for decompression.

4. Cerebellar infarct > 3cm, candidate for decompression.

5. Carotid revascularization.

6. Dx unclear, advanced workup required (neuro opinion, MRI, TOE, LP)

Consultant to consultant

discussion Early advice on Dx

Early advice on interventions

In the future; IV tPA

“Big picture” discussion on goals of transfer

Chance for education

ACUTE STROKE- EVERY MINUTE COUNTS

1 minute= 1.9 million neurons

14 billion synapses

7.5 miles of myelinated fibres

IV tPA meta-analysis – level 1 evidence

Lees et al Lancet 2010

NNT

4.5 9 14.1

Time is BRAIN!

Treatment effect

p<0.001

Interaction with

time p=0.03

4.5 hours

Future strategies Can thrombectomy be expanded to more patients?

Slowing the clock

Expanding the time window

Neuroprotective agents in the field

Figure 1 The stroke emergency mobile unit with CT scanner on boardNote the CT scanner in

the back of the cabin and the separated shielded workstation on the right behind the door.

Weber J E et al. Neurology 2013;80:163-168

© 2013 American Academy of Neurology

Pre-hospital therapies

Jeff Saver California

Unique pre-hospital stroke trial

Ethics considerations

Magnesium IV

1700 patients

72% enrolled < 60 mins post Sx onset

>150 enrolled < 30 mins

62% ischaemic stroke

22% haemorrhage

13% TIAs

3% mimics

Neutral results

Model for the future

Neuroprotective agents in the

field Peptides

Hypothermia

Minocycline

Combinations

Physical methods- TCD

Head positioning

NeuroprotectionPoly-arginine and arginine rich peptides are

neuroprotective in stroke models

Bruno Meloni et al

J Cerebral Blood Flow and Metabolism 2015 Feb 11th

The Perth Intravenous Minocyline

Stroke Study PIMSS

David Blacker

David Prentice

Edith Kohler

Tim Bates

Graeme Hankey

RPH, SCGH,

Swan Districts Hospital, UWA

van Heerden and David BlackerEdith Kohler, David A. Prentice, Timothy R. Bates, Graeme J. Hankey, Anne Claxton, Jolandi

Meta-AnalysisIntravenous Minocycline in Acute Stroke : A Randomized, Controlled Pilot Study and

Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2013 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke published online July 18, 2013;Stroke.

http://stroke.ahajournals.org/content/early/2013/07/18/STROKEAHA.113.000780

World Wide Web at: The online version of this article, along with updated information and services, is located on the

http://stroke.ahajournals.org//subscriptions/

is online at: Stroke Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer process is available in the

Request Permissions in the middle column of the Web page under Services. Further information about thisOnce the online version of the published article for which permission is being requested is located, click

can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Strokein Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions:

by GRAEME HANKEY on July 23, 2013http://stroke.ahajournals.org/Downloaded from

The West Australian Intravenous

Minocycline and tPA Stroke Study

(WAIMATSS)

A pilot study of a strategy to reduce

haemorrhagic transformation

David Blacker

Mike Bynevelt

David Prentice

Graeme Hankey

Tim Bates

Andrew Kelly

Tony Alvaro

20% STROKE: ICH

ICH 30 day Mortality

Broderick et al

9177>60

744930-60

44190-30

GCS 8 or

less

GCS>8Volume

(mls)

Stereotactic ICH Aspiration

ICH is Dynamic

Figure CT scans Baseline noncontrast CT shows heterogeneous right deep parenchymal

hemorrhage (A).

Bermejo P G et al. Neurology 2010;75:834-834

©2010 by Lippincott Williams & Wilkins

Figure 1 Symptomatic hypertensive hemorrhage and multiple microbleeds Transversal CT

scan (A) and T2*-weighted 7-T MRI scan (B) with the symptomatic temporal lobe hemorrhage.

Biessels G et al. Neurology 2010;75:572-573

©2010 by Lippincott Williams & Wilkins

? An endovascular approach

to ICHPerforator stroke following intracranial stenting. A

sacrifice for the greater good?

Levy E, Chaturvedi S.

Neuology 2006;66:1803-4. Editorial

Instead of ...

“Star Trek” approach

Stereotactic DXRT, or US to “cauterise” the

bleeder; activated microbubbles+ haemostatic

drug?

Other issues Secondary prevention strategies

Novel rehabilitation techniques

Organisation of services

Basic sciences

Psychology