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?