Optimizing Care for Patients with Acute Ischemic Stroke ...Optimizing Care for Patients with Acute Ischemic Stroke Thrombolytic Therapy for Low NIHSS Nerses Sanossian, MD, FAHA Presentation

Optimizing Care for Patients with Acute

Ischemic Stroke

Thrombolytic Therapy for Low NIHSS

Nerses Sanossian, MD, FAHA

Presentation not eligible for CME credit

© 2018 Genentech USA, Inc. All rights reserved.

Disclosures


Today’s objectives

Case study: Mary, a 45-year-old Caucasian woman


Every minute counts for patients with AIS


Discussion question

What are the routing considerations

for patients with a suspected stroke?

Please see select Important Safety Information throughout and the full Prescribing Information

available at this presentation.

DEEP

D I V E


AHA/ASA recommendations for EMS

routing of patients with a suspected stroke

The AHA/ASA also states that when several IV alteplase–capable hospital options exist within

a defined geographic region, the benefit of bypassing the closest to bring the patient to one that

offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. Further

research is needed.1

The AHA/ASA recommends patients with a positive stroke screen and/or

a strong suspicion of stroke should be transported rapidly to the closest

healthcare facilities that can capably administer IV alteplase.1

—Class I recommendation, Level of Evidence B-NR

AHA/ASA=American Heart Association/American Stroke Association; NR=nonrandomized.

Reference: 1. Powers WJ, et al. Stroke. 2018;49:e46-e110.



DEEP

D I V E


Considerations for EMS routing of

patients with suspected stroke

FOR PATIENTS WITH A SUSPECTED LVO THAT WERE LAST SEEN NORMAL <3 HOURS AGO*2,3:

ASRH=acute stroke–ready hospital; CSC=comprehensive stroke center;

LVO=large vessel occlusion; PSC=primary stroke center.

References: 1. Powers WJ, et al. Stroke. 2018;49:e46-e110. 2. AHA/ASA Mission: Lifeline

Stroke program. Severity-based stroke triage algorithm for EMS. Published 2017. 3. Trevo

EDFU. Fremont, CA: Stryker International; 2016. 4. Activase [prescribing information].

South San Francisco, CA: Genentech, Inc; 2018.

*Mission: Lifeline Stroke provides timing recommendations based on the

indications for use for mechanical thrombectomy devices.2,3 Activase

administration should occur as soon as possible but within 3 hours after

symptom onset.4 All routing decisions should conform to the regional stroke

systems of care policy.2 Patients suspected by EMS to have had a stroke

but not an LVO should be taken to the nearest stroke center (ASRH, PSC,

or CSC).2

.



The 2018 AHA/ASA Guideline has no recommendation for an EMS routing algorithm

due to insufficient evidence, but states that the Mission: Lifeline Stroke algorithm may

be a reasonable guideline in some circumstances.1

DEEP

D I V E




Considerations when diagnosing

acute ischemic stroke


Discussion question

Case study: Mary, a 45-year-old

Caucasian woman




Discussion question


Is this a disabling stroke?


Determine patient eligibility for Activase® (alteplase)


Activase® (alteplase) Indication

and Important Safety Information


Activase® (alteplase)

Important Safety Information (cont’d)













NINDS: A 2-part, randomized, double-blind

trial of Activase® (alteplase) vs placebo


NINDS: A 2-part, randomized, double-blind

trial of Activase® (alteplase) vs placebo


Activase® (alteplase) significantly reduced

disability in patients with AIS


Activase® (alteplase) safety outcomes when

administered within 3 hours of symptom onset


Activase® (alteplase): An integral part of AIS care




Discussion question


Different imaging modalities have

advantages and limitations1,2








Interfacility transport for patients

receiving Activase® (alteplase)




Streamline the chain of stroke treatment

EXAMPLE OF A STROKE TREATMENT PATHWAY WITH PARALLEL PROCESSES1-3

Multiple parallel processes can help expedite treatment for patients with AIS who are

eligible for Activase® (alteplase) with or without subsequent mechanical thrombectomy1

References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process of

evaluating and stopping stroke. Presentation; 2016. 3. Activase [prescribing information]. South San Francisco, CA: Genentech, Inc; 2018.



DEEP

D I V E


Streamline the chain of stroke

treatment (cont’d)


5

4

DTN=door-to-needle.

References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Kalanithi L, et al. Stroke. 2014;45:3105-3111.

3. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process of evaluating and stopping stroke.

Presentation; 2016. 4. Jauch EC, et al. Stroke. 2013;44:870-947. 5. American Heart Association/American

Stroke Association. Target: Stroke Phase II Campaign Manual. Published October 2014.

*Certain patient evaluations may be performed using

telestroke services.2



DEEP

D I V E


Streamline the chain of stroke

treatment (cont’d)


6

5

References: 1. Goyal M, et al. Stroke. 2014;45:e252-e256. 2. Kalanithi L, et al. Stroke

2014;45:3105-3111. 3. Nguyen-Huynh MN. KPNC stroke EXPRESS: expediting the process

of evaluating and stopping stroke. Presentation; 2016. 4. Activase [prescribing information].

South San Francisco, CA: Genentech, Inc; 2018. 5. Jauch EC, et al. Stroke. 2013;44:870-947.

6. American Heart Association/American Stroke Association. Target: Stroke Phase II Campaign

Manual. Published October 2014. 7. Powers WJ, et al. Stroke. 2015;46:3024-3039.

*Certain patient evaluations may be performed using telestroke services.3

†In centers without capabilities to perform mechanical thrombectomy,

patients should begin receiving Activase before being transferred for

treatment at an experienced stroke center.7



DEEP

D I V E


Summary

Appendix


Examples of imaging for AIS: CT


Examples of imaging for AIS: MR

Documents

Optimizing Care for Patients with Acute Ischemic Stroke ...Optimizing Care for Patients with Acute Ischemic Stroke Thrombolytic Therapy for Low NIHSS Nerses Sanossian, MD, FAHA Presentation