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The Future of Stroke

Debbie Roper, RN, MSN

Vice President of Roper Resources, Inc.

James D. Fleck, M.D.

Medical Director

IU Health Methodist Hospital

Comprehensive Stroke Center

Disclosures

Speaker for Genentech

Speaker for Chiesi

Independent Stroke Consultant

Annual rate of first cerebral infarction by age, sex, and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1999).

Alan S. Go et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Annual age-adjusted incidence of first-ever stroke by race.

Alan S. Go et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Projected total costs of cardiovascular disease (CVD), 2015 to 2030 (2012 $ in billions) in the United States.

Alan S. Go et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Treatment of Acute Ischemic

Stroke

Neuroprotection

Reperfusion

Modified Rankin Score

0 = No symptoms at all

1 = No significant disability despite symptoms: able to carry out all usual duties and activities

2 = Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance

3 = Moderate disability: requiring some help, but able to walk without assistance

4 = Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance

5 = Severe disability: bedridden, incontinent, and requiring constant nursing care and attention

6 = Patient death

Endovascular Ischemic Stroke Treatment

MR CLEAN - NEJM 2015; 372: 11-20

– Multicenter Randomized CLinical trial of Endovascular treatment

for Acute ischemic stroke in Netherlands

ESCAPE – NEJM 2015; 372: 1019-30

– Endovascular treatment for Small Core and Anterior circulation

Proximal occlusion with Emphasis minimizing ct to recanalization

times

EXTEND- IA – NEJM 2015; 372: 1009-18

– EXtending the time for Thrombolysis in Emergency Neurologic

Deficits

SWIFT – PRIME

– Solitaire FR With the Intention For Thrombectomy as PRIMary

Endovascular treatment for acute ischemic stroke

Endovascular Ischemic Stroke Treatment

MR CLEAN – Netherlands

– Age > 18 yrs

ESCAPE – Canada / US / others

– Age > 18 yrs

EXTEND IA – Australia / New Zealand

– Age > 18 yrs

SWIFT PRIME – US / Europe

– Age 18-80 yrs

Endovascular Ischemic Stroke Treatment

# Patients Mean

Age

Occlusion Time

Window

NIHSS

MR CLEAN IA – 233

Control 267

65y Distal ICA

or MCA or

ACA

IA < 6 hr < 2

Mean:

IA 17

Control 18

ESCAPE IA – 165

Control150

70-71y Distal ICA

or MCA

12 hr from

onset (15.5%

> 6 hr)

None at entry

Mean:

IA 16

Control 17

EXTEND IA IV – 35

IV/IA - 35

IV- 70 y

IV/IA – 69y

ICA or

MCA (1st or

2nd

segment)

IV < 4.5 hr

IA start < 6 hr

finish < 8 hr

None at entry

Mean:

IV 13

IV/IA 17

SWIFT

PRIME

IV – 98

IV/IA - 98

IV – 66y

IV/IA – 65y

Distal ICA

or

prox MCA

IA < 6 hr groin

puncture

8-29

Mean:

IV 17

IV/IA 17

Endovascular Ischemic Stroke Treatment

Radiology

Inclusion

ASPECTS % patients

receiving iv

tpa

Median time

stroke onset

to iv tpa

MR CLEAN CTA/MRA Shows

occlusion

No inclusion

#

Median 9

IA 87.1%

Control

90.6%

85-87 min

ESCAPE NCCTASPECTS 6-10

CTAMod-good

collaterals

Median 9 IA 72.7%

Control

78.7%

IA 110 min

Control

125 min

EXTEND IA NCCT

CTA

CTP

100 % IV 145 min

IV/IA 127 min

SWIFT

PRIME

CTA/MRA Shows

occlusion

< 6 was

exclusion

100% IV 117 min

IV/IA 110 min

Endovascular Ischemic Stroke Treatment

IA treatment retrievable

stent

IA

with

GA

Median

stroke

onset to

groin

Median

stroke onset

to

reperfusion

MR

CLEAN

Any type

mechanical

thrombectomy(Rare thrombolytic

agent)

81.5% 37.8% 260 min

ESCAPE Retrievable

stent

recommended (not mandated)

86.1% 9.1% 185 min 218 min

EXTEND

IA

Solitaire 100% 36% 210 min 253 min

SWIFT

PRIME

Solitaire 100% Stroke onset to first

deployment 252 min

Endovascular Ischemic Stroke Treatment

90 day MRS 0-2 TICI 2b/3

MR CLEAN IA – 32.6%

Control – 19.%

OR 2.16 (1.39-3.38)

“Absence residual

occlusion”

IA – 75.4%

Control – 38.9%

ESCAPE IA – 53%

Control – 29.3%

OR 1.7 (1.3-2.2)

IA – 72.4%

EXTEND IA IV -40%

IV/IA – 71%

P = 0.01

IA -86%

SWIFT

PRIME

IV – 35.5%

IV/IA – 60.2%

OR 2.75(1.5-4.95)

IA – 88%

Endovascular Ischemic Stroke Treatment

Symptomatic

ICH

Mortality

MR CLEAN IA – 7.7%

Control – 6.4%

30 day

IA – 18.9%

Control – 18.4%

ESCAPE IA – 3.6%

Control- 2.7%

IA – 10.4 %

Control- 19%

EXTEND IA IV- 6%

IV/IA – 0%

IV – 20%

IV/IA – 9%

SWIFT

PRIME

IV- 3.1%

IV/IA – 1.0%

IV – 12.4%

IV/IA – 9.2%

Endovascular Ischemic Stroke Treatment

Do you have Interventional MDs and

teams?– At your hospital?

– At another hospital?

– Available 24/7/365?

– How do you access Interventional teams?

What advanced imaging is available?

Which patients receive advanced

imaging?

When do patients receive advanced

imaging?

Mobile Stroke Units

Berlin, Germany

Univ Texas-Houston Medical School –

Houston, TX

Cleveland Clinic

Mobile Stroke Units

Mobile Stroke Units

Mobile Stroke Units

Ambulance with CT scanner

Ambulance personnel

EMS organization

Point-of-care labs

Telemedicine connection

Cost

Future of Stroke Care

Future of Stroke Care

Bryan Morton, ReNeuron‘s chairman

• March 2014 - encouraging results of the Phase I

clinical trial of its REN001 treatment for disabled

stroke patients

• Phase II trial is now open for recruitment.

ww.reneuron.com/.../news_ReNeuron%202011%20interim%.

Future of Stroke CareStroke Systems of Cares - Organization

– CSC

– PSC

– Acute Stroke Ready Hospital

– Acute Stroke Ready FSED by DNV

– State laws requiring where patients receive

care

Neuroprotection

– EMS deployment of meds

Enhancing recovery and rehabilitation

Questions?