tPA: Where are we now? What is new? New 30 Minute Door to Needle Target Dr. Kelvin Ng Kuan Huei MBBS MRCP McMaster University / Hamilton Heath Sciences Stroke Program Disclosures None to declare Objectives • Rationale for IV-tPA in acute ischemic stroke • The expanding role for IV-tPA in acute ischemic stroke • Aiming for the 30 minute door to needle target 1
Time is Brain • For every minute delay in treating an ischemic stroke, 1·9 million brain cells die, 13·8 billion synapses, and 12 km of axonal fibers are lost • 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 Rationale for IV-tPA • Two major zones of injury in ischemic stroke • The ischemic core • The penumbra (salvageable) • The penumbra may remain viable for several hours due to collateral flow 2
Rationale for IV-tPA • Improves disability predominantly • IV tPA – 11% absolute benefit compared to placebo (NNT = 9) • Every 15 minutes of expedited start to IV-tPA results in a 4% relative increased likelihood of independence • In Ontario, the proportion of patients treated with IV-tPA is ~ 12% (20-30% are estimated to be eligible) • At HHS in 2015, 23% of all ischemic strokes received IV- tPA The expanding role for IV-tPA in acute ischemic stroke • The age of patients • The severity of the stroke • The extended time window 3
tPA for ischemic stroke is effective irrespective of age with no obvious heterogenous treatment effect No evidence that age modified proportional hazards of alteplase Aiming for the 30 minute door to needle target Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015 4
Working Together • Seamless integration across interprofessional teams • Patients, paramedics, emergency departments, stroke teams, radiology and neurointerventionalist • Parallel processes • Expedited CT imaging including CTA Time is Brain: A Case Study Time Event 5.30am 70 year old man found by wife in bathroom following collapse with left hemiplegia 7.00am EMS activated and patient assessed 7.32am Patient brought into ER 7.39am Non-contrast CT head performed. CTA aborted as patient was agitated and unable to remain still for scan due to neck pain. 8.35am CTA head performed. Decision made not for tPA and for EVT 8.45am Cerebral angiogram and EVT initiated with anaesthetist support Time Event Processes 5.30am 70 year old man found by wife in Early identification of stroke symptoms. bathroom following collapse with left FAST campaign hemiplegia EMS 7.00am EMS activated and patient assessed EMS communication Paramedic on-scene management (recognize and mobilise) Direct transport protocols and pre-alert to ER and stroke team. 7.32am Patient brought into ER Assessment by ER team for stability and expedited imaging 7.39am Non-contrast CT head performed. Assessment by radiology and stroke CTA aborted as patient was agitated physician and EVT team informed. and unable to remain still for scan due Transfer back to ER for monitored light to neck pain. sedation and C-spine assessment 8.35am CTA head performed. Decision made Simultaneous assessment by not for tPA and for EVT radiology, stroke and EVT physician 8.45am Cerebral angiogram and EVT initiated Patient transferred from CT straight to with anaesthetist support endovascular suite Neuro Stepdown team informed of new admission. 5
Objectives • Rationale for IV-tPA in acute ischemic stroke • The expanding role for IV-tPA in acute ischemic stroke • Aiming for the 30 minute door to needle target 6
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