c-stat ed update 3.9.17gaze absent 0 present 2 arm weakness absent 0 present 1 alteration of...
TRANSCRIPT
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ELVO update
Michael Wilder, MD Director, Neurointerventional Program PeaceHealth Sacred Heart Springfield, Oregon
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Riverbend
• 24/7 thrombectomy • ELVO alert • Access PH • PACU • Anesthesia
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Goyal et al. Lancet. 2016
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• 5 landmark RTCs 2015
Goyal et al. Lancet. 2016
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• 5 landmark RTCs 2015
Goyal et al. Lancet. 2016
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• 5 landmark RTCs 2015
– Meta-analysis:
Goyal et al. Lancet. 2016
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• 5 landmark RTCs 2015
– Meta-analysis:– n = 1287
Goyal et al. Lancet. 2016
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• 5 landmark RTCs 2015
– Meta-analysis:– n = 1287– NNT 2.6
Goyal et al. Lancet. 2016
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• ELVO
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• ELVO– Emergent Large Vessel Occlusion
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• ELVO– Emergent Large Vessel Occlusion• <6 hours from onset
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• ELVO– Emergent Large Vessel Occlusion• <6 hours from onset• Without large completed infarct
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• ELVO– Emergent Large Vessel Occlusion• <6 hours from onset• Without large completed infarct• ASPECTS ≥6
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• ELVO– Emergent Large Vessel Occlusion• <6 hours from onset• Without large completed infarct• ASPECTS ≥6
• NIHSS ≥ 6
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• ELVO– Emergent Large Vessel Occlusion• <6 hours from onset• Without large completed infarct• ASPECTS ≥6
• NIHSS ≥ 6• Large vessel occlusion
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• All patients still get IV tPA if eligible
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Every hour of delay leads to 38% decrease in likelihood of good outcome
Menon et al. Stroke 2014
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• Door to groin goal ≤90 minutes
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• Earlier involvement of interventionist • Prior to CT scans being done • CTA head & neck on all stroke alerts
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Field identification of ELVO
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Two questions in the field
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Two questions
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Two questions
1. Is the patient having a stroke?
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Two questions
1. Is the patient having a stroke?2. Does the patient need endovascular
therapy? (ELVO)
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Stroke?
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Cincinnati
“You can’t teach an old dog new tricks”
Los Angeles
Kidwell et al. Stroke 2000
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ELVO?
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Cortical Signs
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• Aphasia
corexel.com
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• Neglect
nature.com
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• Visual field cut
casemed.case.edu
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• Gaze palsy
pixabay.com
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RACE
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LAMS
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C-STATItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Alteration of consciousness
Absent 0
Present 1
C-STAT Positive 2 or greater
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Gaze
• Conjugate gaze deviation (≥1 NIHSS)
• 2 points - highest weight in scale
Yes
No
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Gaze
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GazeItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Level of consciousness Absent 0
Present 1
C-STAT Positive 2 or greater
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GazeItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Level of consciousness Absent 0
Present 1
C-STAT Positive 2 or greater
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Arm Weakness
• Arm (right or left or both) falls to bed before 10 seconds (≥2 NIHSS)
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Arm Weakness
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Arm WeaknessItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Level of consciousness Absent 0
Present 1
C-STAT Positive 2 or greater
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Arm WeaknessItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Level of consciousness Absent 0
Present 1
C-STAT Positive 2 or greater
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Level of consciousness
• Incorrectly answers at least 1 of 2 of LOC questions on NIHSS (age, month) and
• Does not follow at least one of two commands (close eyes, make a fist)
• ≥1 on NIHSS items 1b and 1c
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Level of consciousness
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Level of consciousnessItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Alteration of consciousness
Absent 0
Present 1
C-STAT Positive 2 or greater
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Level of consciousnessItem Findings ScoreGaze Absent 0
Present 2Arm Weakness Absent 0
Present 1Alteration of consciousness
Absent 0
Present 1
C-STAT Positive 2 or greater
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Sensitivity Specificity Positive Likelihood Ratio
Negative Likelihood Ratio
Severe StrokeNIHSS >15
89% 73% 3.3 0.15
Moderate StrokeNIHSS > 10
75% 85% 5.00 0.29
Katz: Stroke 2015;46:1508-1512
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• EMS training next week
• Radio in as “C-STAT positive” if score ≥ 2
• Page out stroke alert as “C-STAT positive”
• Will enable early involvement of interventionist for diagnosis and treatment of ELVO
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Conclusion
• Early recognition is key
• Will allow improved door to groin times
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Suggestions
• CTA head and neck on all stroke alerts
• Alert interventionist prior to imaging if cortical findings and weakness
• C-STAT
• Stroke activation order set placed prior to pt arrival
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Thank you