Endovascular Treatment for Acute Ischemic Stroke Provincial Review - PowerPoint PPT Presentation

Endovascular Treatment for Acute Ischemic Stroke Provincial Review Presentation by by Dr Dr Grant Stot otts Dr Dr Tim imo Kri rings On beh ehalf lf of of th the e OSN Endovascula lar Treatment Im Imple lementation Pla lanning Group February 3 & 5 2016

2 Pre-presentation Instructions • Please keep microphone on mute unless you are asking a question • The ppt will be available at www.ontariostrokenetwork.ca • There will be a question and answer period at the end of the presentation • This presentation is being webcasted and will be archived at: http://webcast.otn.ca

3 Presenters & Presentation Objectives Presenters: • Dr Grant Stotts, Stroke Neurologist, Champlain Regional Stroke Medical Director, Co-Chair • Dr Timo Krings, Interventional Neuroradiologist, University Health Network- TWH, Co-Chair • Obje jectiv ives: • Provide a brief overview of the draft Endovascular Treatment recommendations for Ontario • Provide an opportunity to discuss and provide input on implementation considerations to inform planning. • Provide an opportunity for discussion and Q&A

EVT Background Dr Grant Stotts

5 Background - Acute Stroke • Stroke is the 3 rd leading cause of death • ~170,000 Ontarians are experiencing the effects of stroke • In Ontario > 20,000 patients have a stroke or TIA every year - one stroke every 10 minutes • Stroke costs Canadian economy $3.6 billion • Each hour in which treatment does not occur, the brain loses as many neurons as it does in almost 3.6 years of normal aging • Outcomes: o Death (15%) o Moderate to Severe Impairment (40%) o Severely Disabled (10%) o Minor Impairment or Disability (25%) o Recover Completely (10%) Heart & Stroke Foundation Canada & OSN

6 Acute Ischemic Stroke (AIS) and its Rx • Pre-2015, standard of care for acute ischemic stroke was in intravenous (IV (IV) ) tissue Plasminogen Activator (tPA) thrombolysis • IV tPA – 11% absolute benefit compared to placebo (NNT = 9) • BU BUT benefit is significantly less in large artery occlusions • Some patients unable to receive IV tPA due to contra-indications (e.g. bleeding risk, recent surgery) • # Ontarians with AIS receiving IV tPA has plateaued at 12% • Limitations of IV tPA prompted study of endovascular treatment (EVT) with mechanical embolectomy

7 Chain* of Stroke Treatment • Detection Patient Education • Transfer to a stroke centre EMS/Ambulance • Medical evaluation ED/Neurology • Imaging Neuroradiology • Acute treatment Neurology/Neuro- Interventional teams • Post-acute treatment care Stroke Unit • Rehabilitation Rehab Centre • Prevention Stroke Prevention Clinic *The cha hain in is is as as stro trong as as its its wea eakest lin link

8 Ottawa Hospital Annual Report 2014-15 Front Page

9 Patient Experiences • Mr. Claude Corneau was the first patient treated in the ESCAPE trial in Ottawa • He is 70 years old and presented unable to speak or move his right side • After EVT, he was able to return to work as a mechanic within a few days and celebrated his 50 th wedding anniversary that summer with his wife.

Endovascular Treatment What is it and what is the evidence? Dr Timo Krings

Acute Stroke Rx Rx until 2011 Functional outcome scale: mRS 0-2 = independent; mRS 3-5 = disability; mRS 6 = dead Add reference

Impact of Artery Recanalization Review of Published Papers (1985-2002, N=2066) Percentage patients Intracerebral Hem emorrhage OR: 4.43 OR: 0.24 (CI: 3.32-5.91) (CI: 0.16-0.35 ) Rha & Saver. Stroke 2007

13 The New Standard of Care for Large Artery AIS in 2015 – Mechanical Embolectomy with or without IV tPA Procedure involves using a catheter and stent, inserted through an artery in the groin to grab the clot and pull it out St Stent re retrie ievers

One of f the Clo lots Ext xtracted

15 Evidence from Other Trials MR CLEAN ESCAPE EXTEND-IA SWIFTPRIME

16 Effect Size for Intervention C ommon OR* (“shift”) 3.1 3.1 (2. (2.0-4.7) ) NNT** ~ ~ 3 3 for im improvement on on mRS .3%  53 mRS 0-2 29 29.3 53.0 .0% NNT = = 4 4 for in independence .0%  10 De Death HR* R* 19 19.0 10.4 .4% 0.4 0.4 (0. (0.2-0.8) *Adjusted for age, sex, baseline NIHSS score, baseline ASPECTS score, IV alteplase use, baseline occlusion location ** ** NNT = number needed to treat for one to have an excellent recovery 04/02/2016 WWW.ESCAPETRIAL.ORG

17 Perspective • Antibiotics for ear infection NNT = 8 • Intravenous thrombolysis (stroke) NNT = 9 • Cardiac stenting (STEMI) NNT = 9

ESCAPE Tri rial Results

19 Who Is Eligible for EVT ? - 20% of ischemic stroke patients - With or without IV tPA - Disabling stroke - Stroke symptoms within 6 hours of time last seen normal - Large blood vessel blockage with a reachable clot - Brain tissue that is still alive

EVT Working Group Dr Grant Stotts

21 Key Factors for Success • Similar to other acute treatments for acute ischemic stroke: TIM TIME and SP SPEED! • Imaging (CTA) is key to ide identif ific icatio ion of target arterial occlusion and extent of infarct with enough brain to save • Ensure minimal time lapse between brain imaging and recanalization, which includes:  no delay in initiating IV thrombolysis when appropriate  rapid access to and assessment of all relevant imaging (via Telestroke/ENITS) by neurology and/or interventional teams  rapid coordinated transfer to endovascular site/suite in consultation with Stroke Neurologist and neurointerventionalist  minimize time from groin puncture to recanalization

22 Implementation Planning Working Group To develo lop an im imple lementatio ion str trategy to: • Estimate patient volumes at provincial, LHIN, stroke centre and facility levels to inform planning/impact • Identify facility capacity (focus on physicians and staff expertise and imaging resources) • Determine role of Provincial Telestroke Program • Determine impacts to Emergency Medical Services and current Provincial Paramedic Acute Stroke Protocol • Develop protocols for treatment and transfer • Identify strategies for knowledge translation • Evaluate processes/outcomes (with minimum data set)

Mem embership 23 Nam Name Organiz izatio ion Role ole Dr Tim imo Krings Univ niversit ity y He Healt alth Netw Network-Toronto Western Hos Hospital Interventio tional l Ne Neuroradio iolo logis ist, Co-Chair ir Dr Grant t Sto totts ts The he Ottawa Hos Hospital Str troke Ne Neurologis ist, t,Co-Chair ir Dr Dr Che heemun Lu Lum The he Ottawa Hos Hospital l Interventio tional l Ne Neuroradio iolo logis ist Dr Sac achin in Pan andey Lo London He Healt alth Scie iences- Interventio tional l Ne Neuroradio iolo logis ist Dr Vic ictor Yan ang Sunn unnyb ybrook k He Healt alth Scie iences Ne Neurosurgery Dr Vit itor Pereir ira- Univ niversit ity y He Healt alth Netw Network Ne Neurosurgery Dr Walt alter Mon ontanera St Michael’s Hospital Interventio tional l Ne Neuroradio iolo logis ist Dr Lau Laurie ie Mor orris ison St Michaels ls Hos Hospit ital Eme Emergency Medic icin ine Dr Le Lean anne Cas asaubon Univ niversit ity y He Healt alth Netw Network Str troke Ne Neurologis ist, t,OSN SN Best Prac actic ice Cham ampio ion Dr Ric ick k Sw Swar artz Sunn unnyb ybrook k He Healt alth Scie iences Str troke Ne Neurologis ist Dr Frank Silv lver Univ niversit ity y He Healt alth Scie iences Str troke Ne Neurologis ist t (Tele lestrok oke) Dr Jennif ifer Man andzia ia London He Lo Healt alth Scie iences Str troke Ne Neurologis ist Dr Al Jin King ngston Gene neral l Hos Hospital- Str troke Ne Neurologis ist Dr Jas ason Prpic ic Chair air EHS EHS MAC Bas ase Hos Hospit ital l Medic ical l Dir irector, Eme Emergency MD, Beth th Li Linkewic ich Nor North and nd Eas ast Tor oronto Str troke Ne Netw twork Regio ional l Prog ogram Dir irector Jac acqueli line Wi Wille llem South Eas ast Toronto Regio ional l Prog ogram Dir irector Rhon onda McNic icoll ll-Whit iteman Ham Hamilt ilton He Heal alth th Scie iences Clin inic ical l Nur Nurse Spe pecialis list- Str troke Best Prac actic ice Coo oordin inator Caterina Kmill mill Nor North West Ontario io Str troke Ne Netw twor ork Regio ional l Prog ogram Dir irector Denis ise St. Lo Louis is Wi Windsor Regio ional l Hos Hospital Distric ict Str troke Coo oordinator Gina Tom omaszewski ki Acute Car are Best Prac actic ice Coo oordin inator SW SWO Str troke Netw Network Li Lind nda Kello loway Best t Prac actic tice Le Lead ader Ontario io Stroke Netw Network

EVT Centres in in Ontario

Current EVT Centres WITH ITH 24/7 /7 COVERAGE WITH ITHOUT T 24/7 /7 COVERAGE 1. London Health Sciences 1. Hamilton Health Sciences 2. Ottawa Hospital 2. Kingston General Hospital (pending) 3. St Michael’s Hospital 3. Thunder Bay Regional Health 4. Sunnybrook Health Centre Centre 5. Toronto Western Hospital 4. Trillium Health Partners 5. Windsor Regional Hospital