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Implications for Clinical Practice

Implications for Clinical Practice. Jeffrey L. Saver, MD Professor of Neurology Director, UCLA Stroke Center . --All slides in presentation are freely available under a Creative Commons “Share Freely with Attribution” License – Saver . Talk Outline.

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Implications for Clinical Practice

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  1. Implications for Clinical Practice Jeffrey L. Saver, MD Professor of Neurology Director, UCLA Stroke Center --All slides in presentation are freely available under a Creative Commons “Share Freely with Attribution” License – Saver

  2. Talk Outline • Implications for clinical practice guidelines • Statistical significance • Implications for clinicians at bedside • Clinical significance • Systems of care • Implications for future

  3. Guidelines

  4. European EUSI Recommendations 2006

  5. US AHA/ASA Guidelines 2010

  6. INTERACT 2: A Near Win Trial

  7. Stroke and Near Win Trials

  8. Meta-Analysis of INTERACT 1, 2 and ATACH Trials

  9. Clinical Significance “A difference, to be a difference, must make a difference”

  10. INTERACT 2

  11. INTERACT 2

  12. INTERACT 2

  13. Benefit on Dichotomized Outcome • 52.0% vs 55.6% • ARR 3.6% • Benefit per Thousand: 36 • NNT: 27.8

  14. INTERACT 2

  15. INTERACT 2

  16. Automated Algorithmic Joint Outcome Table Analysis --Saver et al, Stroke 2009;40:2433-7

  17. Benefit Over All Health State Transitions • Benefit per Thousand: 81 • NNT: 12.3

  18. Benefit in INTERACT 2 vs Other Acute Stroke Interventions --Samsa et al, Am Heart J 1998;136:703-13 --Saver, Stroke 2007;38:3055-3062 --Saver et al, Stroke 2009;40:2433-7

  19. Door to BP Control in Community Practice in ICH • 100 patients, 32 Emergency Departments • At ED arrival • NIHSS 18 • Time from LKW 63 mins • Mean BP 176/94 • 54% received BP therapy in ED • Among the 48 patients with SBP ≥ 180 • Control (<180) never achieved in 19% • Median door to control 118 mins • Door to control ≤ 90m in 31% --Sanossian et al, Ann Emerg Med 2012;60: S56

  20. Other Treatment Recommendations for ICH • ICU monitoring • Antipyretics in febrile patients • Early mobilization • ICP management • Head of bed, analgesia, sedation • Osmotic diuretics, CSF drainage, hyperventilation • Maintain serum glucose < 185 • Seizures • Prophylactic antiepileptics for lobar ICH • Antiepileptics for clinical seizures • Antiepileoptics for electrographic seizures • DVT prophylaxis • Intermittent compression on arrival • SQ LMWH or UH after 3-4d • For DVT, consider vena cava filter • Reversal of coagulopathies • Protamine for heparin • Vitamin K, PCC, rF7 for warfarin • Surgery • Definite for select cerebellar • Consider for lobar • Consider minimally invasive for deep --Morgenstern et al, Stroke 2010

  21. NINDS Time Goals ICH Critical Pathway Identify Signs of Possible Stroke Monitor Blood Glucose and Treat (if needed) Critical EMS Assessments & Actions BP Management Immediate General Assessment/Stabilization ICP Management Immediate Neurologic Assessment (stroke team or designee) Seizure Prevention and Management Does CT scan show hemorrhage? Fluid Management Body Temperature Management No Hemorrhage Hemorrhage Surgical Treatment of ICH • Cerebellar hemorrhage >3 cm with neurologic deterioration or brain stem compression and/or hydrocephalus • Consider in lobar clots <1 cm of surface Possible ischemic stroke Consult neurologist or neurosurgeon If not available, consider transfer Begin ICH Pathway • Admit to stroke unit (if available) or ICU • Monitor BP and treat (if indicated) • Monitor neurologic status (emergent CT if deterioration) • Monitor blood glucose & treat (if needed) • Supportive therapy • Treat comorbidities AHA Adult Stroke Guidelines. Circulation. 2005;112(suppl 24):IV-111-IV-120; Broderick J, et al. Stroke. 2007;38:2001-2023; Qureshi AI, et al. N Engl J Med. 2001;344:1450-1460.

  22. ICH Critical Pathway Sample Checklist ICH Critical Pathway Sample Checklist Assessment Nursing Testing

  23. ICH Critical Pathway Sample Checklist (cont.) ICH Critical Pathway Sample Checklist (cont.) Medications Consults Pathways Adapted from AHA Adult Stroke Guidelines. Circulation. 2005;112(suppl 24):IV-111-IV-120; Broderick JP, et al. Stroke. 1999;30:905-915; Broderick J, et al. Stroke. 2007;38:2001-2023; Marik PE, et al. Chest. 2002;122:699-711; Passero S, et al. Epilepsia. 2002;43:1175-1180; Qureshi AI, et al. Stroke. 2001;33:1916-1919.

  24. Next Steps

  25. Time is Brain for Hemorrhagic Stroke --Arima et al, Stroke 2012;43:2236-8

  26. Dynamics of Hyperacute Hematoma Growth 0-120 Minutes: Not Well Delineated --Kazui et al, Stroke 1996;27:1783-1787

  27. Intracerebral Hemorrhage and the Golden Hour • Narrow therapeutic time window • Early intervention critical • Prehospital personnel • 35-70% of stroke patients arrive by ambulance • Unique position: first medical professional to come in contact with stroke patient

  28. CT scan evaluated Final Hematoma Volume Established Initial ED Evaluation CT scan obtained EMS Arrival in ED Hospital Treatment initiated EMS Arrival Activation of EMS Volume of Hematoma in mL EMS Transport Rupture of blood vessel Onset of Symptoms Time in minutes from onset of symptoms Sanossian, FAST-BP Trial

  29. CT scan evaluated Final Hematoma Volume Established Initial ED Evaluation CT scan obtained EMS Arrival in ED Hospital Treatment initiated EMS Arrival Activation of EMS Volume of Hematoma in mL EMS Transport Goal: Control Hematoma expansion Earlier in Course Field Treatment Initiated Rupture of blood vessel Onset of Symptoms Time in minutes from onset of symptoms Sanossian, FAST-BP Trial

  30. CT scan evaluated Final Hematoma Volume Established Initial ED Evaluation CT scan obtained EMS Arrival in ED Hospital Treatment initiated EMS Arrival Activation of EMS Volume of Hematoma in mL EMS Transport Goal: Control Hematoma expansion Earlier in Course Field Treatment Initiated Rupture of blood vessel Onset of Symptoms Time in minutes from onset of symptoms Sanossian, FAST-BP Trial

  31. Onset to Treatment Times in Recent Trials Enrolling ICH Patients

  32. Preserve / Treat / Cure

  33. Preserve / Treat / Cure

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