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Advances in Stroke CareNASEMSO 2017 March
Ken Williams, MD, FACEP, FAEMSMDC Chair
Disclosures
No financial conflicts to disclose.
I work at the RIH ED, and am Medical Director for LifePACT (ground CCT team) and the Center for EMS, RI DOH.
I’m the NASEMSO MDC Chair.
Thank You
Dr. Ryan McTaggart for use of his slides and data.
Greetings from Rhode Island!
The Ocean State
NASEMSO 2018 in Rhode Island
Providence
Gratuitous picture of where I work.
And another….
And another….
OK, time for the wayback machine….
Pre-1960s
EMS brings everyone to the closest hospital.
Pretty much.
Trauma, STEMI, Stroke –
That’s too bad, we’ll care for you here.
1960s-1970s
TRAUMA: First Trauma Centers open.
Concept of bypass – direct to Trauma Center appearsTakes a long time and lots of research and politics to become widespread
STEMI – “He’s too unstable to transfer! He’s having a heart attack!”
STROKE – That’s too bad.
1980s
TRAUMA50% of HEMS missions are scene trauma “Golden Hour”
MTOS showing improved survival with trauma center care
STEMIHeart attacks are caused by blood clots! We can dissolve them and “balloon open” the atherosclerotic vessel in the cath lab. Does every chest pain patient need one of those (rare) cath labs?
Death rate about 25% ISIS-2 ASA in MI GISSI, GUSTO, TIMI-1 PERIPHERAL lytic therapy safe
STROKEThat’s too bad. We’ll start arranging rehab.
See Maroo, Topol The early history and development of thrombolysis in acute myocardial infarction. J Thromb Haemost 2004;2: 1867-70
1990sTRAUMA
Acceptance of regional trauma systems of care
STEMIEnough cath labs to allow lytic + PCI (“facilitated” PCI)
STROKETissue Plasminogen Activator for Acute Ischemic Stroke (NINDS)
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group*
N Engl J Med 1995; 333:1581-1588 December 14, 1995 DOI: 10.1056/NEJM199512143332401
2000s
TRAUMA: Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011
Patients meeting criteria should go directly to the nearest / highest trauma center.
STEMI: Recommendations for Criteria for STEMI Systems of Care
standardized reperfusion STEMI care pathway that designates primary PCI as the preferred reperfusion strategy if initiated within 90 minutes
STROKE: After negative NC CT, tPA (or other lytic) within the “window”.
1995-2012 Stroke Trials
Green = Good
Yellow = ???
Red = Harm
Does it look better to you?
Hoffman & SchrigerAnn Emerg Med 2009 Sep;54(3):329-36
2010s
TRAUMAReduced MVC death rate.
Direct to trauma center well accepted (where geography allows).
STEMIReduced death rate.
Direct to PCI center after EMS 12-lead well accepted (where geography allows).
STROKEWhy we’re here!
Saving lives…but that’s another lecture….
Current TherapySuspect StrokeCall 911EMS completes Stroke Screening Tool / ProtocolCall “Stroke Alert” if YES to all
Onset < 6 hoursGlucose > 50Abnormal Cincinnati Stroke ScaleNo head trauma or other cause
Transport to regional destination (Stroke Ready, Primary Stoke Center, CSC)
At the Hospital….• CT to determine
hemorrhagic vs ischemic.
• Evaluate for indications, contraindications, mimics.
• Give tPA if indicated.
• Admit or transfer.
OutcomeOverall, some improvement in function measured at several months.
“Miracle” recoveries occur, but most are likely clots that break up on their own, or TIAs, or mimics.
And some patients have devastating intracranial hemorrhage after tPA.
What’s Going On?
We’ve been treating stroke as a single entity, with limited knowledge, averaging results from multiple study patients.
Symptoms? Within window? No bleed on CT? tPA for you!
Kind of like:Trauma? Shock? Positive FAST? Out with your spleen!Chest Pain? Abnormal ECG? Lyse everything but don’t cath and fix the lesion!
What’s Really Happening?
Brains vary.Strokes vary.Treatment should be individualized (vary).
Bleeds and large strokes.
Small strokes and TIAs
Small strokes and TIAs
Bleeds and large strokes.
Most other patients improve regardless of treatment.
But where is YOUR patient? How do we evaluate and treat the variability?
What did you say?
IV tPA is NOT the primary treatment solution for the most severe strokes
Game changer.
Really.
Four Lessons
1. Time (alone) does not matter. Brain matters.
2. Stroke is a vascular disease. Image the vessels.
3. Brains vary. Vasculature varies. Symptoms vary. Strokes vary.
4. MT is the best treatment for ELVO strokes.
Lesson One: Brain matters more than time.
The Window is going – out the window.
Sure, time is brain, but in many patients there is collateral flow and viable ischemic brain MANY hours after the “window” closes.
Unfortunately, there are also patients with large hemispheric infarction an hour after symptom onset (who bleed if lysed – explaining some of the patients on the NINDS graph).
69 yo wake up stroke NIHSS 28
Target Name
This patient
Goal
Door to MRI 5 minutes <10 minutes
MRI DTD 15 minutes <20 minutes
Done? DescriptionYes Pre-notify MRI tech with name,
age, Cr, and patient family contact
Yes Prenotify MRI team when patient 10 minutes from arrival to RIH
Yes Prenotify Critical Care resource nurse
Yes Prenotify ED CC attending and resident
Yes CC nurse brings 3-5mg of Versed to scanner for sedation if needed
Christmas Miracle!
This is a completed infarct --“futile infarct”
Maybe time is too crude a criterion.Maybe tissue-based selection is the better choice.
Lesson Two: Image the Vessels (not just the brain).
Everyone (almost) gets a CTA
Image the vessels!
Some also need a rapid MRI to evaluate infarct / ischemic area.
Imaging in 2017Need to exclude the worst thing it could be (bleed).
Need to identify ELVO if present.
Routine vessel imaging is key to accomplishing this.
CTA triages patients for therapy and helps predict outcome.
CTA is to ELVO what ECG is to STEMI
CTA in the hospital, or the MSU.
With teleradiology to NIR stroke team in real time.
For too long, we have used imaging to view the sequelae of an acute neurovascular event rather
than looking at the primary problem.
Acute vascular syndromes
Pulmonary Embolism CT Pulmonary Angiogram
Aortic Dissection CT Angiogram Aorta
Traumatic Carotid/Vertebral Injury CTA Neck
Acute Lower extremity ischemia CTA or DSA Lower extremity
require acute vascular imaging
Strokes are
Acute stroke syndromes are a vascular problemAcute Cerebral Ischemia
LVO No LVO
Small Vessel Occlusion
“TIA”
Hypo-perfusion
Lacunar Stroke
Vessel imaging at presentation on all patients allows for detection of LVO andpossible etiology
CardioembolicCervical Carotid or Vertebral Atherosclerosis
Intracranial AtherosclerosisDissectionE
tiolo
gies
Emergent Imaging: CTA / MRI• CTA / MRI ???
• In an ambulance ???
Univ of Tennessee MSU CT angio Siemens SOMATOM scanner
Triage in the field?
Primary Stroke Center
Comprehensive Stroke Center
NO YES
ELVO ??
Why?
• To evaluate for hemorrhage.
• To find the ELVOs (not the Waldos).
Lesson Three: Brains (and strokes) Vary.
Types of Stroke
• Hemorrhagic 10%
• Ischemic 90%
What’s an ELVO?
• Emergency Large Vessel Occlusion.
• A subcategory of ischemic stroke.
A new term to describe the sickest of the stroke patients.
Will allow for simplified communication across systems of care.
EmergencyLarge Vessel Occlusion
Stroke
Presence of ELVO may be more common than thought.
Series YearPublished
Number of Patients
Incidence of LVO
Maas et al. 2009 699 377 (54%)
Hansen et al. 2014 637 183 (29%)
Heldner et al. 2013 2152 1043 (49%)
Why find the ELVOs?
They are the strokes that are best treated with MT (mechanical thrombectomy) using the latest stent-retrievers by Neuro Interventional Radiologists (NIR).
What about scores?• Scores are useful for YES / NO stroke ( with other data, like blood sugar ).
• They MAY be helpful in selecting patients more likely to have ELVO strokes.
Relying on NIHSS alone without routine vessel imaging can falsely give us a sense of
security in patients who actually have large vessel occlusion.
Scores help, but….
About 1/3-1/2 of patients with high scores have a problem treatable with VIR / MT.
But we are seeing TIA patients with M1 LVO occlusions that resolve spontaneously!
Brains vary, and so do the vascular collaterals….
Scores of scores….
Stroke Scores1. Cincinnati Prehospital Stroke Scale (CPSS) 2. Face Arm Speech Test (FAST) 3. Los Angeles Prehospital Stroke Screen (LAPSS) 4. Medic Prehospital Assessment for Code Stroke (Med PACS) 5. Melbourne Ambulance Stroke Screen (MASS) 6. Ontario Prehospital Stroke Screening Tool (OPSS) 7. Recognition of Stroke in the Emergency Room Score (ROSIER)
Severity Scales1. Rapid Arterial Occlusion Evaluation Scale (RACE) 2. Los Angeles Motor Scale (LAMS) 3. Kurashiki Prehospital Stroke Scale (KPSS) 4. National Institutes of Health Stroke Scale (NIHSS) 5. sNIHSS-8 6. sNIHSS-5 7. Cincinnati Prehospital Stroke Severity Scale (CPSSS)
Brains Differ• The “window” of 3, 4.5, or 6 hours
was based on averages of patients in studies.
• It turns out that brains have variablecollateral vessels.
• So the SAME clot in the SAME place may cause very DIFFERENT infarct/ischemic patterns in two different patients
Imaging determines candidacy for embolectomyNOT TIME
Goyal M et al. in review
Gotta have it by 2.5 hours!
tPA ???Patients with contraindications to tPA are now frequently treated successfully with clot retrieval with GREAT results.
Peripheral tPA is NOT good at dissolving large clots (ELVO).
Lesson Four: MT is the best treatment for ELVO strokes, NOT tPA.
IV vs IANeurology (peripheral tPA)
vs
Neuro-Interventional Radiology (NIR) (MT)
How about a team approach, a system approach?
• Rapid recognition.
• 911 activation.
• Screening.
• Transport to best receiving center.
Clot Retrieval ?
• What’s that?
Stent-retrievers: A better tool
Example: 84 year old male, Left MCA occlusion
#N/A
#N/A #N/A
#N/A
(all$times$in$minutes)
#N/A #N/A
#N/A#N/A
#N/A
#N/A
The(patient(has(made(a(near(complete(recovery.((Current(NIHSS(is(0(with(no(deficit.((Expected(to(be(discharged(home(without(need(for(rehabilitation.
Rapid,(complete(recanalization(was(achieved(within(24(minutes(of(groin(puncture,(and(within(2(hours(from(the(CTA(confirming(occlsuion(of(the(MCA.((Having(a(CTA(at(the(outside(hospital(allowed(us(to(mobilize(the(interventional(team(in(advance(and(transport(the(patient(directly(to(the(angio(suite(rather(than(stopping(in(the(ED.
Comprehensive Stroke Center Stroke ELVO Transfer Followup
Recent trials: Summary
19%
28%36%
29%
40%
31%
44%
60%53%
71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
MR CLEAN(n=500)
REVASCAT(n=206)
SWIFT-PRIME(n=196)
ESCAPE(n=316)
EXTEND-IA(n=74)
Modified Rankin Score 0-2 at 90 days
Control Intervention
All p <.005
Recent trials: Remarkable Safety
6%
2% 3% 3%6%
8%
2%0%
4%0%
0%2%4%6%8%
10%12%14%16%18%20%
Symptomatic Intracranial Hemorrhage
Control IA
No increased risk of Hemorrhage with IA therapy in any of the trials
Recent trials: Global Impact
ESCAPE
SWIFT-PRIME
EXTEND-IA
REVASCAT
MR CLEAN
How important is this?
SWIFT-PRIME
EXTEND-IA
ESCAPE
MR CLEAN
PCI vs. Thrombolysis for STEMI: Prevention of
MI/Stroke/Death
REVASCAT
Defibrillation for Cardiac Arrest
What did you say?
• Too complicated? Being done in many US urban areas and other countries. Rural implementation is a challenge (currently)
• Too expensive? Not compared to the cost of stroke care.
• Inadequate resources? Same issue that we had with STEMI in the 1980s.
Over 110 JC Advanced
Comprehensive Stroke Centers
6381 DSC Advanced Comprehensive Stroke Center Virginia Commonwealth University Health System Richmond VA 23298-0510 Certification 04/10/2015
6387 DSC Advanced Comprehensive Stroke Center Bon Secours-St. Mary's Hospital Richmond VA 23226 Certification 05/25/2016
7656 DSC Advanced Comprehensive Stroke Center University of Wisconsin Hospitals and Clinics Authority Madison WI 53792 Certification 10/07/2016
9617 DSC Advanced Comprehensive Stroke Center Harborview Medical Center Seattle WA 98104 Certification 08/08/2015
7675 DSC Advanced Comprehensive Stroke Center Aurora Health Care Metro, Inc. Milwaukee WI 53201-2901 Certification 07/27/2016
7718 DSC Advanced Comprehensive Stroke Center Froedtert Memorial Lutheran Hospital, Inc Milwaukee WI 53226 Certification 05/30/2015
9540 DSC Advanced Comprehensive Stroke Center Intermountain Medical Center Murray UT 84157-7000 Certification 01/20/2016
9216 DSC Advanced Comprehensive Stroke Center Bexar County Hospital District San Antonio TX 78229-4493 Certification 02/26/2016
9081 DSC Advanced Comprehensive Stroke Center Memorial Hermann Hospital Houston TX 77030-1501 Certification 06/27/2015
538795DSC Advanced Comprehensive Stroke Center UT Southwestern Zale-Lipshy University Hospital Dallas TX 75390-9227 Certification 01/09/2016
7892 DSC Advanced Comprehensive Stroke Center Vanderbilt University Medical Center Nashville TN 37232-2101 Certification 09/23/2015
7850 DSC Advanced Comprehensive Stroke Center Fort Sanders Regional Medical Center Knoxville TN 37916 Certification 03/07/2015
7853 DSC Advanced Comprehensive Stroke Center The University of Tennessee Medical Center Knoxville TN 37920 Certification 06/20/2015
7874 DSC Advanced Comprehensive Stroke Center Methodist Healthcare Memphis Hospitals Memphis TN 38104 Certification 01/10/2017
7887 DSC Advanced Comprehensive Stroke Center TriStar Skyline Medical Center Nashville TN 37207 Certification 12/20/2014
7809 DSC Advanced Comprehensive Stroke Center Chattanooga Hamilton County Hospital Authority Chattanooga TN 37403 Certification 12/12/2015
6584 DSC Advanced Comprehensive Stroke Center Medical University of South Carolina Medical Center Charleston SC 29425 Certification 01/31/2016
8877 DSC Advanced Comprehensive Stroke Center Mercy Hospital Oklahoma City, Inc. Oklahoma City OK 73120 Certification 11/11/2016
6158 DSC Advanced Comprehensive Stroke Center West Penn Allegheny Health System, Inc. Pittsburgh PA 15212 Certification 10/08/2016
6132 DSC Advanced Comprehensive Stroke Center Thomas Jefferson University Hospitals, Inc. Philadelphia PA 19107 Certification 10/08/2015
6075 DSC Advanced Comprehensive Stroke Center The Milton S. Hershey Medical Center Hershey PA 17033 Certification 10/28/2015
6169 DSC Advanced Comprehensive Stroke Center UPMC Presbyterian Shadyside Pittsburgh PA 15213 Certification 04/11/2015
5651 DSC Advanced Comprehensive Stroke Center Rhode Island Hospital Providence RI 02903 Certification 09/28/2016
6129 DSC Advanced Comprehensive Stroke Center Hospital of the University of Pennsylvania Philadelphia PA 19104 Certification 11/16/2016
9705 DSC Advanced Comprehensive Stroke Center Providence St. Vincent Medical Center Portland OR 97225 Certification 06/09/2016
9707 DSC Advanced Comprehensive Stroke Center OHSU Hospitals and Clinics Portland OR 97239-3098 Certification 04/29/2015
6013 DSC Advanced Comprehensive Stroke Center Abington Memorial Hospital Abington PA 19001 Certification 07/29/2015
4880 DSC Advanced Comprehensive Stroke Center Lehigh Valley Hospital Allentown PA 18105 Certification 08/13/2016
201590DSC Advanced Comprehensive Stroke Center OU Medical System Oklahoma City OK 73104 Certification 12/07/2016
8909 DSC Advanced Comprehensive Stroke Center St. John Medical Center, Inc. Tulsa OK 74104 Certification 08/08/2015
6988 DSC Advanced Comprehensive Stroke Center University of Cincinnati Medical Center, LLC Cincinnati OH 45219 Certification 06/04/2015
3771 DSC Advanced Comprehensive Stroke Center The MetroHealth System Cleveland OH 44109-1998 Certification 08/10/2016
7001 DSC Advanced Comprehensive Stroke Center The Cleveland Clinic Foundation Cleveland OH 44195 Certification 04/27/2016
7017 DSC Advanced Comprehensive Stroke Center University Hospitals Cleveland Medical Center Cleveland OH 44106 Certification 01/14/2015
7029 DSC Advanced Comprehensive Stroke Center Ohio State University Hospitals Columbus OH 43210 Certification 01/24/2015
7030 DSC Advanced Comprehensive Stroke Center Riverside Methodist Hospital Columbus OH 43214-3998 Certification 11/22/2014
7035 DSC Advanced Comprehensive Stroke Center Miami Valley Hospital (Main Site), Dayton OH Dayton OH 45409 Certification 02/09/2015
7110 DSC Advanced Comprehensive Stroke Center Mercy Health- St. Vincent Medical Center LLC Toledo OH 43608 Certification 12/19/2016
7111 DSC Advanced Comprehensive Stroke Center The Toledo Hospital Toledo OH 43606 Certification 06/09/2016
2091 DSC Advanced Comprehensive Stroke Center North Shore University Hospital Manhasset NY 11030 Certification 02/10/2015
5820 DSC Advanced Comprehensive Stroke Center NYU Hospitals Center New York NY 10016 Certification 09/04/2015
5829 DSC Advanced Comprehensive Stroke Center Mount Sinai Hospital New York NY 10029-6574 Certification 04/08/2015
5838 DSC Advanced Comprehensive Stroke Center NewYork-Presbyterian Hospital New York NY 10065 Certification 06/03/2016
5856 DSC Advanced Comprehensive Stroke Center Strong Memorial Hospital Rochester NY 14642 Certification 12/05/2015
208281DSC Advanced Comprehensive Stroke Center Capital Health System, Inc. Trenton NJ 08638 Certification 09/30/2015
5994 DSC Advanced Comprehensive Stroke Center Overlook Medical Center Summit NJ 07902-0220 Certification 11/08/2016
2357 DSC Advanced Comprehensive Stroke Center Mercy Hospital of Buffalo Buffalo NY 14220 Certification 12/02/2015
6569 DSC Advanced Comprehensive Stroke Center Novant Health Forsyth Med Ctr dba for Forsyth Memorial Hosp. Winston Salem NC 27103 Certification 01/23/2015
6571 DSC Advanced Comprehensive Stroke Center North Carolina Baptist Hospital Winston Salem NC 27157 Certification 05/30/2015
6478 DSC Advanced Comprehensive Stroke Center University of North Carolina Hospitals Chapel Hill NC 27514 Certification 12/13/2014
6490 DSC Advanced Comprehensive Stroke Center Duke University Hospital Durham NC 27710 Certification 08/01/2015
5923 DSC Advanced Comprehensive Stroke Center JFK Medical Center Edison NJ 08818-3059 Certification 12/22/2016
5960 DSC Advanced Comprehensive Stroke Center Jersey Shore University Medical Center Neptune NJ 07754-0397 Certification 07/11/2016
5969 DSC Advanced Comprehensive Stroke Center Robert Wood Johnson University Hospital New Brunswick NJ 08903-2601 Certification 08/06/2015
5963 DSC Advanced Comprehensive Stroke Center University Hospital Newark NJ 07103-2406 Certification 07/29/2015
7485 DSC Advanced Comprehensive Stroke Center Henry Ford Health System Detroit MI 48202 Certification 05/11/2016
7510 DSC Advanced Comprehensive Stroke Center McLaren Flint Medical Center Flint MI 48532 Certification 09/24/2016
7539 DSC Advanced Comprehensive Stroke Center Bronson Methodist Hospital Kalamazoo MI 49007 Certification 08/13/2015
7540 DSC Advanced Comprehensive Stroke Center Sparrow Health System Lansing MI 48912 Certification 11/22/2014
7580 DSC Advanced Comprehensive Stroke Center William Beaumont Hospital Royal Oak MI 48073-6769 Certification 12/03/2016
2908 DSC Advanced Comprehensive Stroke Center University of Minnesota Medical Center, Fairview Minneapolis MN 55455 Certification 05/27/2016
8181 DSC Advanced Comprehensive Stroke Center Mayo Clinic Hospital —Rochester Rochester MN 55902-1906 Certification 05/01/2015
8185 DSC Advanced Comprehensive Stroke Center Regions Hospital Saint Paul MN 55101 Certification 12/09/2015
4760 DSC Advanced Comprehensive Stroke Center SSM Health DePaul Hospital - St. Louis Bridgeton MO 63044-2588 Certification 11/14/2015
8351 DSC Advanced Comprehensive Stroke Center Saint Luke's Hospital of Kansas City Kansas City MO 64111 Certification 07/16/2016
8387 DSC Advanced Comprehensive Stroke Center Barnes-Jewish Hospital Saint Louis MO 63110 Certification 10/17/2015
8063 DSC Advanced Comprehensive Stroke Center St. Dominic - Jackson Memorial Hospital Jackson MS 39216-4699 Certification 03/18/2016
7457 DSC Advanced Comprehensive Stroke Center Regents of the University of Michigan Ann Arbor MI 48109 Certification 06/15/2016
8777 DSC Advanced Comprehensive Stroke Center Ochsner Clinic Foundation New Orleans LA 70121 Certification 07/10/2015
6264 DSC Advanced Comprehensive Stroke Center University of Maryland Medical Center Baltimore MD 21201-1595 Certification 03/16/2016
3956 DSC Advanced Comprehensive Stroke Center Johns Hopkins Bayview Medical Center Baltimore MD 21224-2780 Certification 08/25/2016
6252 DSC Advanced Comprehensive Stroke Center The Johns Hopkins Hospital Baltimore MD 21287 Certification 07/11/2015
7767 DSC Advanced Comprehensive Stroke Center University Medical Center, Inc. Louisville KY 40202 Certification 02/06/2015
7756 DSC Advanced Comprehensive Stroke Center Baptist Health Lexington Lexington KY 40503 Certification 02/01/2017
7760 DSC Advanced Comprehensive Stroke Center University of Kentucky Hospital Lexington KY 40536-0293 Certification 11/14/2015
7770 DSC Advanced Comprehensive Stroke Center Norton Hospitals, Inc. Louisville KY 40222 Certification 10/20/2015
8780 DSC Advanced Comprehensive Stroke Center Tulane University Hospital and Clinic New Orleans LA 70112 Certification 05/13/2015
8609 DSC Advanced Comprehensive Stroke Center Via Christi Hospitals Wichita, Inc. Wichita KS 67214 Certification 02/26/2016
8567 DSC Advanced Comprehensive Stroke Center The University of Kansas Hospital Authority Kansas City KS 66160-7200 Certification 09/10/2016
188549DSC Advanced Comprehensive Stroke Center Indiana University Health, Inc. Indianapolis IN 46202 Certification 07/27/2016
7315 DSC Advanced Comprehensive Stroke Center University of Chicago Medical Center Chicago IL 60637 Certification 09/05/2015
7410 DSC Advanced Comprehensive Stroke Center OSF Saint Francis Medical Center Peoria IL 61637 Certification 09/21/2016
7444 DSC Advanced Comprehensive Stroke Center Central DuPage Hospital Association Winfield IL 60190 Certification 03/21/2015
7431 DSC Advanced Comprehensive Stroke Center Memorial Medical Center Springfield IL 62781-0001 Certification 09/28/2015
6850 DSC Advanced Comprehensive Stroke Center Public Health Trust of Dade County Florida Miami FL 33136-1094 Certification 01/13/2017
6852 DSC Advanced Comprehensive Stroke Center Baptist Hospital of Miami Miami FL 33176-2197 Certification 08/31/2016
3506 DSC Advanced Comprehensive Stroke Center Grady Memorial Hospital Corporation Atlanta GA 30303 Certification 08/01/2015
6689 DSC Advanced Comprehensive Stroke Center Emory University Hospital Atlanta GA 30322 Certification 04/17/2015
6656 DSC Advanced Comprehensive Stroke Center AU Medical Center, Inc. Augusta GA 30912 Certification 05/06/2015
6711 DSC Advanced Comprehensive Stroke Center WellStar Kennestone Hospital Marietta GA 30060 Certification 04/30/2015
10235 DSC Advanced Comprehensive Stroke Center The Queen's Medical Center Honolulu HI 96813 Certification 12/21/2016
8266 DSC Advanced Comprehensive Stroke Center State University of Iowa Iowa City IA 52242 Certification 03/07/2015
4656 DSC Advanced Comprehensive Stroke Center Northwest Community Hospital Arlington Heights IL 60005 Certification 11/09/2016
7282 DSC Advanced Comprehensive Stroke Center The Board of Trustees of the University of Illinois Chicago IL 60612 Certification 06/22/2015
7267 DSC Advanced Comprehensive Stroke Center Northwestern Memorial Hospital Chicago IL 60611 Certification 06/15/2016
7297 DSC Advanced Comprehensive Stroke Center Rush University Medical Center Chicago IL 60612 Certification 11/11/2015
7340 DSC Advanced Comprehensive Stroke Center Alexian Brothers Medical Center Elk Grove Village IL 60007-3397 Certification 01/17/2015
369946DSC Advanced Comprehensive Stroke Center Mayo Clinic Florida Jacksonville FL 32224 Certification 06/15/2016
6804 DSC Advanced Comprehensive Stroke Center Shands Teaching Hospitals & Clinics, Inc. Gainesville FL 32608 Certification 08/20/2016
6953 DSC Advanced Comprehensive Stroke Center Palmetto General Hospital Hialeah FL 33016 Certification 06/17/2016
6237 DSC Advanced Comprehensive Stroke Center Christiana Care Health Services Newark DE 19713 Certification 06/22/2016
9389 DSC Advanced Comprehensive Stroke Center Swedish Medical Center Englewood CO 80113 Certification 02/28/2015
2649 DSC Advanced Comprehensive Stroke Center Hartford Hospital Hartford CT 06102-5037 Certification 04/25/2015
5677 DSC Advanced Comprehensive Stroke Center Yale - New Haven Hospital New Haven CT 06510-3203 Certification 05/12/2016
4265 DSC Advanced Comprehensive Stroke Center St. Anthony Hospital Lakewood CO 80228 Certification 07/16/2015
6308 DSC Advanced Comprehensive Stroke Center MedStar Washington Hospital Center Washington DC 20010 Certification 06/08/2016
6310 DSC Advanced Comprehensive Stroke Center The George Washington University Hospital Washington DC 20037 Certification 11/26/2015
10052 DSC Advanced Comprehensive Stroke Center Kaiser Foundation Hospital - Sacramento Sacramento CA 95825 Certification 01/27/2017
10000 DSC Advanced Comprehensive Stroke Center University of California Irvine Orange CA 92868 Certification 10/24/2015
9908 DSC Advanced Comprehensive Stroke Center Long Beach Memorial Medical Center Long Beach CA 90806 Certification 01/20/2017
10100 DSC Advanced Comprehensive Stroke Center Regional Medical Center of San Jose San Jose CA 95116 Certification 12/16/2015
10101 DSC Advanced Comprehensive Stroke Center Good Samaritan Hospital, LP San Jose CA 95124 Certification 03/11/2015
10071 DSC Advanced Comprehensive Stroke Center University of California San Diego Medical Center San Diego CA 92103-8949 Certification 09/16/2015
10010 DSC Advanced Comprehensive Stroke Center Stanford Health Care Stanford CA 94305 Certification 12/14/2016
9384 DSC Advanced Comprehensive Stroke Center University of Colorado Hospital Authority Aurora CO 80045 Certification 05/30/2015
10038 DSC Advanced Comprehensive Stroke Center Kaiser Foundation Hospital - Redwood City Redwood City CA 94063 Certification 12/29/2015
9944 DSC Advanced Comprehensive Stroke Center Ronald Reagan UCLA Medical Center Los Angeles CA 90095 Certification 11/08/2016
9792 DSC Advanced Comprehensive Stroke Center Cedars-Sinai Medical Center Los Angeles CA 90048 Certification 12/06/2014
9880 DSC Advanced Comprehensive Stroke Center Scripps Memorial Hospital La Jolla La Jolla CA 92037 Certification 01/17/2015
9838 DSC Advanced Comprehensive Stroke Center St. Jude Medical Center Fullerton CA 92835 Certification 04/24/2015
2814 DSC Advanced Comprehensive Stroke Center University of Alabama at Birmingham Birmingham AL 35249-1900 Certification 04/29/2015
5052 DSC Advanced Comprehensive Stroke Center Mercy San Juan Medical Center Carmichael CA 95608 Certification 08/03/2016
At RIH
The median D2N time for tPA cases at RIH is 38 minutes.
(Yes, we use tPA for non-ELVO strokes within “the window” and/or with ischemic brain at risk on MRI)
Thanks to EMS PTS, MedCom, direct-to-CT, stroke team, ED staff!
MT for ELVOGWTG (3425 pts) RIH (from 2016
Age median 71 77
NIHSS arrival median 17 18
NIHSS discharge median 4 (>50% home without nursing)
Door-thrombectomy attempt 127 67
Door-thrombectomy <60mins 5% 47%
Door-thrombectomy <90mins 20% 64%
Cases / quarter 11.8 41.25
How we are doing this - 911
Stroke Protocol: ID, LAMS triage within 30 mins to CSC
MedCom and PTS
Direct to CT for NC and CTA
Rapid DW MRI when indicated
Stroke Team response and NIR vs ED
Awesome ED & NIR staff
How we are doing this – transfer.
• Arrival at OSH• Rapid CT / CTA and consult with NIR via Express Care
• LifePACT dispatched on consult.
• LifePACT arrival simultaneous with NIR read of CTA (usually)• Transport and treatment decision (tPA, tPA and transfer for MRI / NIR)
• Note – no teleneurology. NIR trusts ED physician exam / NIHSS
So, come to the Ocean State in 2018
Happy to arrange a tour.
And you can enjoy the views.
Outside
And inside
stay safe
