the future of stroke james d. fleck, m.d. medical director iu health methodist hospital...

The Future of Stroke

James D. Fleck, M.D.Medical Director

IU Health Methodist Hospital

Comprehensive Stroke Center

Disclosures

None

Stroke StatisticsHeart Disease and Stroke Statistics 2014

~795,000 new or recurrent strokes/year

87% Ischemic, 10% ICH, 3% SAH

1 stroke every 40 seconds in US

1 death from stroke every 4 minutes in US

4Th leading cause of death in US

Decline in stroke mortality

US age-standardized death rates* attributable to CVD, 2000 to 2010.

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

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

Prevalence of stroke by age and sex (National Health and Nutrition Examination Survey: 2007–2010).



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



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



The 22 leading diagnoses for direct health expenditures, United States, 2010 (in billions of dollars).



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



Treatment of Acute Ischemic Stroke

Neuroprotection

Reperfusion

Time Is Brain !!

Neurons Lost

Synapses Lost

Accelerated Aging

Per Stroke 1.2 billion 8.3 trillion 36 yrs

Per Minute 1.9 million 14 billion 3.1 wks

Per Hour 120 million 830 billion 3.6 yrs

Modified Rankin Score

0 = No symptoms at all1 = No significant disability despite symptoms: able to carry out all usual duties and activities2 = Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance3 = Moderate disability: requiring some help, but able to walk without assistance4 = Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance5 = Severe disability: bedridden, incontinent, and requiring constant nursing care and attention6 = 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


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

AgeOcclusion Time

WindowNIHSS

MR CLEAN IA – 233Control 267

65y Distal ICA or MCA or

ACA

IA < 6 hr < 2Mean:IA 17 Control 18

ESCAPE IA – 165Control150

70-71y Distal ICA or MCA

12 hr from onset (15.5%

> 6 hr)

None at entryMean:IA 16Control 17

EXTEND IA IV – 35IV/IA - 35

IV- 70 yIV/IA – 69y

ICA or MCA (1st or

2nd segment)

IV < 4.5 hrIA start < 6 hr finish < 8 hr

None at entryMean:IV 13IV/IA 17

SWIFT PRIME

IV – 98IV/IA - 98

IV – 66yIV/IA – 65y

Distal ICA or

prox MCA

IA < 6 hr groin puncture

8-29Mean:IV 17IV/IA 17

Endovascular Ischemic Stroke TreatmentRadiologyInclusion

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 minControl 125 min

EXTEND IA NCCTCTACTP

100 % IV 145 minIV/IA 127 min

SWIFTPRIME

CTA/MRA Shows

occlusion

< 6 was exclusion

100% IV 117 minIV/IA 110 min

CT Angiography and Perfusion

CT Perfusion

ASPECTS

Endovascular Ischemic Stroke TreatmentIA treatment retrievable

stentIA

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


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%


SymptomaticICH

Mortality

MR CLEAN IA – 7.7%Control – 6.4%

30 dayIA – 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%


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

PHANTOM –S – Prehospital Acute Neurological Treatment and

Optimization of Medical Care in Stroke Study– Berlin Germany– STEMO – Stroke Emergency Mobile– JAMA 2014; 311: 1622-1631

PHANTOM-S

Mean alarm-to-treatment time– 51.8 min– 76.3 min control/usual time– No increased risk for intracerebral

hemorrhage or death

Mobile Stroke Units

Ambulance with CT scanner

Ambulance personnel

EMS organization

Point-of-care labs

Telemedicine connection

Cost

Future of Stroke Care

Organization– PSC and CSC– State laws requiring where patients receive

care

Neuroprotection– EMS deployment of meds

Enhancing recovery and rehabilitation

Questions?

the future of stroke james d. fleck, m.d. medical director iu health methodist hospital...

Documents

stroke mortality slide

acute ischemic stroke

prevalence of stroke

yrs slide

patient death slide

future of stroke james

primary endovascular

severe disability