Seeing Wisely: Decoding Stroke Care with Dr. Ben Newman

“The value of experience is not in seeing much, but in seeing wisely.”
― Sir William Osler

 

Deciphering signal from noise as it relates to modern stroke care can be challenging and conflicting, especially as it pertains to the out of hospital environment. In this podcast, we brought the knowledge and experience of Dr. Ben Newman: a neurosurgeon and endovascular therapy expert to discuss advances, challenges, and strategies in caring for our stroke patients.

When to Bypass

Perhaps the most challenging decision to make when presented with a patient experiencing an acute stroke is the transport decision. Should we transport them to a Comprehensive Stroke Center (CSC), or to a "thrombolytic capable center"? 

The 2018 AHA/ASA Stroke Guidelines state 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.

They also state that the  Mission: Lifeline Severity–based Stroke Triage Algorithm for EMS may be reasonable in some circumstances. This algorithm recommends, in some circumstances, transporting the patient to a comprehensive center only if the transport time is "<15 additional minutes compared with the travel time to the closest primary stroke center or acute stroke-ready hospital." In the podcast, Dr. Newman believes that the travel time past a "lytic" capable center should be limited to 20, maybe even 30 minutes. 

Where you transport stroke patients to should be determined by your local protocols and Medical Director in coordination with local experts. Here are a few considerations:

Patients with contraindications to thrombolytics may still be candidates for thrombectomy.  Last Known Well (LKW) isn't much of a factor in thrombectomy decision making. Patients with a "wake up stroke" may still be thrombectomy candidates depending upon the results of CTA and perfusion imaging. Comprehensive Stroke Centers typically see a high volume of stroke patients and have a well established work flow that results in above average door to needle times. Transporting the patient further might result in an overall shorter time to thrombolytic administration.  Most patients with LVO, although candidates for thrombolytics, are less likely to respond, and may be at increased risk for intra-cerebral hemorrhage. 

When to Suspect LVO

It should be noted that the prevalence of LVO varies greatly in the literature, ranging anywhere from 5 to 50%, meaning that very There are multiple stroke severity algorithms of which even less consensus exists! Essentially, these scales that were originally developed and validated to recognize strokes have been adapted by adding percentage points to determine severity.  So, most of your stroke "screening" tools now have an associated "severity" tool. 

The bottom line is, pick one screening tool for your department, preferably the one you currently use, and use the "sister" severity tool and get really good at it, then evaluate for over or under triage. 

Our (Curbside to Bedsides) recommendation is that if your department doesn't have a standardized severity tool patients who are having classic, unequivocal stroke symptoms (dominant hemisphere deficits, gaze deviations, flaccidity, speech deficits, etc.), are likely experiencing a LVO. 

 

 

References

Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega-Gutierrez, S., … Lansberg, M. G. (2018). Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1713973 Campbell, B. C. V., Donnan, G. A., Lees, K. R., Hacke, W., Khatri, P., Hill, M. D., … Davis, S. M. (2015). Endovascular stent thrombectomy: The new standard of care for large vessel ischaemic stroke. The Lancet Neurology. https://doi.org/10.1016/S1474-4422(15)00140-4 De La Ossa, N. P., Carrera, D., Gorchs, M., Querol, M., Millán, M., Gomis, M., … Dávalos, A. (2014). Design and validation of a prehospital stroke scale to predict large arterial occlusion : The rapid arterial occlusion evaluation scale. Stroke. https://doi.org/10.1161/STROKEAHA.113.003071 Froehler, M. T., Saver, J. L., Zaidat, O. O., Jahan, R., Aziz-Sultan, M. A., Klucznik, R. P., … Mueller-Kronast, N. H. (2017). Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke). Circulation. https://doi.org/10.1161/CIRCULATIONAHA.117.028920 Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J., … Hill, M. D. (2015). Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1414905 Goyal, M., Menon, B. K., Van Zwam, W. H., Dippel, D. W. J., Mitchell, P. J., Demchuk, A. M., … Jovin, T. G. (2016). Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. The Lancet. https://doi.org/10.1016/S0140-6736(16)00163-X Hastrup, S., Damgaard, D., Johnsen, S. P., & Andersen, G. (2016). Prehospital acute stroke severity scale to predict large artery occlusion: Design and comparison with other scales. Stroke. https://doi.org/10.1161/STROKEAHA.115.012482 Jovin, T. G., Chamorro, A., Cobo, E., de Miquel, M. A., Molina, C. A., Rovira, A., … Dávalos, A. (2015). Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1503780 Lambrinos, A., Schaink, A. K., Dhalla, I., Krings, T., Casaubon, L. K., Sikich, N., … Hill, M. D. (2016). Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review. Canadian Journal of Neurological Sciences. https://doi.org/10.1017/cjn.2016.30 Moore, J. M., Griessenauer, C. J., Gupta, R., Adeeb, N., Patel, A. S., Ogilvy, C. S., & Thomas, A. J. (2016). Landmark papers in cerebrovascular neurosurgery 2015. Clinical Neurology and Neurosurgery. https://doi.org/10.1016/j.clineuro.2016.06.007 National Stroke Foundation. (2010). Clinical guidelines for stroke management 2010. National Stroke Foundation. https://doi.org/10.1007/978-981-10-9035-6_165
Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., … Jovin, T. G. (2017). Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1706442 Smith, W. S., Lev, M. H., English, J. D., Camargo, E. C., Chou, M., Johnston, S. C., … Furie, K. L. (2009). Significance of large vessel intracranial occlusion causing acute ischemic stroke and tia. Stroke. https://doi.org/10.1161/STROKEAHA.109.561787 Smith, W. S., Sung, G., Saver, J., Budzik, R., Duckwiler, G., Liebeskind, D. S., … Gobin, Y. P. (2008). Mechanical thrombectomy for acute ischemic stroke: Final results of the multi MERCI trial. Stroke. https://doi.org/10.1161/STROKEAHA.107.497115

 

“The value of experience is not in seeing much, but in seeing wisely.” ― Sir William Osler

 

Deciphering signal from noise as it relates to modern stroke care can be challenging and conflicting, especially as it pertains to the out of hospital environment. In this podcast, we brought the knowledge and experience of Dr. Ben Newman: a neurosurgeon and endovascular therapy expert to discuss advances, challenges, and strategies in caring for our stroke patients.

When to Bypass

Perhaps the most challenging decision to make when presented with a patient experiencing an acute stroke is the transport decision. Should we transport them to a Comprehensive Stroke Center (CSC), or to a "thrombolytic capable center"? 

The 2018 AHA/ASA Stroke Guidelines state 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.

They also state that the  Mission: Lifeline Severity–based Stroke Triage Algorithm for EMS may be reasonable in some circumstances. This algorithm recommends, in some circumstances, transporting the patient to a comprehensive center only if the transport time is "