Update in Ischemic Stroke 2004

Timothy Lukovits, M.D.Co-Director, Dartmouth Stroke Program

““Stroke Unit” 1960 and Stroke Unit” 1960 and 20042004

Stroke Care 1960Stroke Care 2004

ACGME-approved stroke fellowshipsACGME-approved stroke fellowships ABPN subspecialty certification in ABPN subspecialty certification in

stroke neurologystroke neurology

Expected benefits of primary stroke Expected benefits of primary stroke centerscenters

Improved efficiency of patient careImproved efficiency of patient care Fewer peri-stroke complicationsFewer peri-stroke complications Increased use of acute stroke therapiesIncreased use of acute stroke therapies Reduced morbidity and mortalityReduced morbidity and mortality Improved long-term outcomesImproved long-term outcomes Reduced costsReduced costs Increased patient satisfactionIncreased patient satisfaction

Checks patient information against applicable AHA/ASA Guidelines (Stroke

and CAD)

Checks patient information against applicable AHA/ASA Guidelines (Stroke

and CAD)

Copyright restrictions may apply.

LaBresh, K. A. et al. Arch Intern Med 2004;164:203-209.

Pilot data from the New England Get With the Guidelines program (12-month results)

Also, health departments in Mass. and NY beginning certification of stroke centers

Question 1 for the audienceQuestion 1 for the audience

Is there a need for stroke centers?Is there a need for stroke centers? YesYes NoNo

Question 2 for the audienceQuestion 2 for the audience

Does the benefit of t-PA outweigh the Does the benefit of t-PA outweigh the risk?risk? YesYes NoNo

8 years after FDA approval 8 years after FDA approval and and

even more controversial !even more controversial !

DWI DWI (Diffusion Weighted Imaging)(Diffusion Weighted Imaging)

PWIPWI(Perfusion Weighted Imaging)(Perfusion Weighted Imaging)

Isolated weakness right index fingerJS Kim, Neurology, 2002

Diffusion weighted imagingDiffusion weighted imaging

“Mismatch” = PWI volume 20% >DWIvolumeGood tPA candidate

Possible tPA candidate

Questionable tPA candidate

Amyloid angiopathy: a risk Amyloid angiopathy: a risk factor for warfarin and factor for warfarin and

thrombolytic related ICH:thrombolytic related ICH:

CT/CTA

CTPerfusion

PWI/DWI/MRA

Mechanical thrombolysisMechanical thrombolysis

Advantages of mechanical Advantages of mechanical thrombolysisthrombolysis

Decreased or no need for lytic agentDecreased or no need for lytic agent More rapid and effective clot More rapid and effective clot

disruptiondisruption

Concentric Retriever deviceConcentric Retriever device

FDA approval August 2004FDA approval August 2004

Ultrasound-enhanced lysisUltrasound-enhanced lysis

Carotid stentingCarotid stenting

Carotid angioplasty and Carotid angioplasty and stenting: an evolving stenting: an evolving

technologytechnology

FDA HDE for PFO closure FDA HDE for PFO closure devicesdevices

How do we apply these How do we apply these advances in New Hampshire?advances in New Hampshire?

We have many small hospitals We have many small hospitals separated by miles, mountains and separated by miles, mountains and misgivings? misgivings?

Limited interest or resources in Limited interest or resources in stroke stroke

Stroke Medical DRGs 9/99-Stroke Medical DRGs 9/99-10/0110/01

Stroke DRG Admissions 9/99-10/01 DHMCConcordCMCElliotLRGHPortsmouthSt. JosephWentworth-DouglassSouthern NHFrisbee MemorialExeterParklandCheshire AVHFranklinMonadnockMemorial HospitalLittletonCottagePorterWeeksSpeareNew LondonUpper Connect.APD

Hospitals that appear to have basic Hospitals that appear to have basic infrastructure to meet BAC Criteria infrastructure to meet BAC Criteria for Primary Stroke Centers (24/7 for Primary Stroke Centers (24/7 blood studies, Stroke QI program, ED, blood studies, Stroke QI program, ED, Stroke Care map, t-PA protocol, Stroke Care map, t-PA protocol, prewritten stroke orders): prewritten stroke orders):

33

American Heart AssociationAmerican Heart Association

North East Stroke Taskforce StructureNorth East Stroke Taskforce Structure

Northeast Affiliate, Health Initiatives, Advocacy & Communications

Committee

ME StrokeTaskforce

NH StrokeTaskforce

RI StrokeTaskforce

VT Stroke Taskforce

North East Stroke Taskforce (NEST)

Chairperson, Lee Schwamm, MD

MA StrokeTaskforce

Upstate NYStroke Taskforces:

Albany,Buffalo & Syracuse

AHA/ASA “Local Market” Stroke Taskforces

Rev. 6/30/04

NH stroke task forceNH stroke task forceTimothy Lukovits, MDTimothy Lukovits, MD Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterDonna Clark, MDDonna Clark, MD Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterJonathan Friedman, M.D.Jonathan Friedman, M.D. Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterRobert Zwolak, M.D.Robert Zwolak, M.D. Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterParker Towle, M.D.Parker Towle, M.D. Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterSarah Johansen, MDSarah Johansen, MD Dartmouth Hitchcock Medical CenterDartmouth Hitchcock Medical CenterWendi Guillette, OTR/LWendi Guillette, OTR/L Healthsouth Rehabilitation HospitalHealthsouth Rehabilitation HospitalElva Hawkins, RNElva Hawkins, RN Elliot HospitalElliot HospitalDavid Hogarty, MDDavid Hogarty, MD Healthsouth Rehabilitation HospitalHealthsouth Rehabilitation HospitalPatricia Locuratolo, MDPatricia Locuratolo, MD Neurologist - PortsmouthNeurologist - PortsmouthDouglas Black, MDDouglas Black, MD Neurologist - PortsmouthNeurologist - PortsmouthArchie McGowan, MDArchie McGowan, MD Portsmouth Radiological Associates, PAPortsmouth Radiological Associates, PARachel RoweRachel Rowe Foundation for Healthy CommunitiesFoundation for Healthy CommunitiesSue PrentissSue Prentiss NH EMSNH EMSPowen HsuPowen Hsu New Era MedicineNew Era MedicineCraig DayCraig Day AHA/ ECC Manager – ME, NH, VTAHA/ ECC Manager – ME, NH, VTNancy PederziniNancy Pederzini AHA/ Advocacy Director – NH AHA/ Advocacy Director – NH

Stroke Educ. activities in Stroke Educ. activities in NH/VTNH/VT

Concord Neurology for Primary CareConcord Neurology for Primary Care November 19, 2003November 19, 2003Concord (NH Brain Injury Assoc. Meeting) Concord (NH Brain Injury Assoc. Meeting) November 19, 2003November 19, 2003DHMC Rehab ConferenceDHMC Rehab Conference March 2, 2004March 2, 2004DHMC Rehab Conference DHMC Rehab Conference March 9, 2004March 9, 2004New LondonNew London May 3, 2004May 3, 2004Berlin (AVH)Berlin (AVH) May 18, 2004May 18, 2004Nashua (Southern NH Medical Center)Nashua (Southern NH Medical Center) June 24, 2004June 24, 2004Concord Neurology for Primary Care Concord Neurology for Primary Care November 10, 2004November 10, 2004NH Medical SocietyNH Medical Society November 10, 2004November 10, 2004Huggins Hospital (NH Emergency Medicine)Huggins Hospital (NH Emergency Medicine) November 18, 2004November 18, 2004DHMC Cardiology ConferenceDHMC Cardiology Conference December 6, 2004December 6, 2004Woodsville (Cottage)Woodsville (Cottage) December 21, 2004December 21, 2004Elliot HospitalElliot Hospital January 20, 2005January 20, 2005

Norwich, VT EMTs Norwich, VT EMTs January 5, 2004January 5, 2004Woodstock, VT Primary Care Neurology ConferenceWoodstock, VT Primary Care Neurology Conference February 25, 2004February 25, 2004Stowe, VT Northern New England Neurology ConferenceStowe, VT Northern New England Neurology Conference February 26, 2004February 26, 2004Bennington, VT (Southwestern VT Medical Center) Bennington, VT (Southwestern VT Medical Center) September 11, 2004September 11, 2004

Other Task Force ActivitiesOther Task Force Activities

Meeting in Portsmouth, NH January Meeting in Portsmouth, NH January 20052005

Encourage use of GWTG-Stroke and Encourage use of GWTG-Stroke and Primary Stroke Center conceptPrimary Stroke Center concept

Why should we consider Why should we consider organizing stroke care organizing stroke care

regionally?regionally?Networking will improve use of limited Networking will improve use of limited resourcesresources We can share continuing education activitiesWe can share continuing education activities We can share limited diagnostic and therapeutic We can share limited diagnostic and therapeutic

resources (e.g., subspecialty cerebrovascular resources (e.g., subspecialty cerebrovascular disease care for complicated cases)disease care for complicated cases)

Imagine a new revolutionary treatment becomes Imagine a new revolutionary treatment becomes availableavailable

Improved patient access to clinical studiesImproved patient access to clinical studiesWe can learn from and be stimulated by We can learn from and be stimulated by

each others’ experiences and enthusiasmeach others’ experiences and enthusiasm

CASESCASES

Case 1Case 1

A 49 yo male was evaluated because of sudden left-sided numbness and

weakness.

Two weeks prior to my evaluation, he developed sudden numbness of the

left arm and leg and he had difficulty moving the arm but he was able to

drive his truck a short distance. He was evaluated at a small community

hospital and his symptoms improved over the next couple of days. He

had an MRI and was told it was normal and was discharged with a

diagnosis of “neurologic migraine or RIND”. This caused confusion

because he still had a sense of numbness and heaviness in the left arm and

he felt like his thought processes were slowed. On examination, I found

that he had mild weakness of the left arm and leg and some psychomotor

slowing.

Small filling defect (?embolus) in the mid to distal left

pericallosal artery.

3 x 3 cm pulmonary AVM in the left lower lobe.

Case 2Case 2

Case 3Case 3

CConfused onfused

VVascularascular

AAnalysesnalyses

We need to prevent CVAs!