STROKE POTPOURRI
Very Recent Advances In Stroke
Management
Arlyn Valencia, M.D.
Neurologist, Stroke Subspecialist
Diplomat...
STROKE IS
TREATABLE!!!!
America's Stroke Burden
Someone in the United States has a stroke every 40 seconds.
Every four minutes someone dies of str...
POTPOURRI OF LATEST ADVANCES AND
KNOWLEDGE IN STROKE MANAGEMENT
• Acute Stroke Intervention
1. Intravenous and Intrarteria...
THE COAGULATION CASCADE
Intravenous rt-PA is recommended for selected patients
who may be treated within 3 hours of onset of ischemic
stroke (Clas...
Intravenous fibrinolysis with rt-PA within 3 and 4.5 h was also
shown to be safe in large European observational study
(SI...
Population Not Studied
Additional "exclusion criteria" for the 3–4.5 h time window"
1. Age >80 years
2. Very severe defici...
NINDS TPA Stroke Trial
Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit
Excellent outcome at 3 months on all scal...
NINDS TPA Stroke Trial
Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit
Excellent outcome at 3 months on all scal...
Door to IV TPA Goal ≤ 60 Minutes
=
Time is Brain
• STARS Registry
• 38 community, 18 academic hospitals, 389 IV TPA pts
• ...
NEUROIMAGING MODALITIES
CT SCAN
CEREBRAL PERFUSION IMAGING
A 64-year-old man presenting with
headache and acute aphasia.
A. NCCT shows no evidence of acut...
CTA and MRA
CONVENTIONAL ANGIOGRAPHY
CAROTID DUPLEX
Acute Stroke Intervention
1. Intravenous and Intrarterial TPA
2. Intraarterial Clot Retrieval
3. Cerebral Stenting And Ang...
The Dreaded DENSE MCA SIGN
Massive Cerebral Edema with Midline Shift and
Brainstem Compression
Combined Intravenous and Intra-Arterial r-TPA
Therapy of Acute Ischemic Stroke
Emergency Management of Stroke (EMS) Bridgi...
CAROTID ENDARTERECTOMY
THROMBECTOMY
MECHANICAL CLOT RETRIEVAL
Mechanical thrombectomy after IV tPA seems
as safe as mechanical thrombectomy alone.
Mechanical ...
THE MERCI DEVICE
The device was initially approved in August 2004 and is
currently labeled under the following indication:...
The MERCI RETRIEVER
THE SOLITAIRE DEVICE
SWIFT
Results from the SWIFT (Solitaire with the intention for
thrombectomy) study show that the Solitaire FR
revascularis...
Other SWIFT Findings
• Two per cent of Solitaire-treated patients had symptoms of
bleeding in the brain, compared with 11%...
NO MERCY FOR MERCI
“We are going from our first generation of clot-
removing procedures, which were only
moderately good i...
ICD:The Wingspan System: Everyone Just Got Stent
Happy
SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial
Arterial Stenosis
Patients who had a recent transien...
1. Aggressive medical management plus percutaneous
transluminal angioplasty and stenting (Wingspan stent system )
2. Contr...
STROKE PREVENTION
• Nothing Beats Aggressive Medical
Management for Stroke Prevention!!
What Is It Exactly??
The WARCEF Trial
• Coumadin or ASA for Cardiomyopathy
(WARCEF Trial- Warfarin VS Aspirin on Patients
With Reduced Cardiac ...
Stroke Prevention for Patients with Reduced
Ejection Fraction
WARCEF PRIMARY ENDPOINT
End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio
(95% CI)
p
Death, ischemic
stroke or
intra...
WARCEF: PRIMARY OUTCOME
COMPONENTS
End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio
(95% CI)
p
Death
Ischemic
strok...
WARCEF answers an important clinical question.
It's a conundrum that we face every day between
cardiology and neurology, w...
INTRACEREBRAL HEMORRHAGE WITH
INTRAVENTRICULAR EXTENSION
THE ROLE OF
INTRAVENTICULAR TPA
AND MY VERY OWN
INTRAVENTRICULAR
...
Empirical characteristics of litigation involving TPA and
ischemic stroke.
CONCLUSION:
The available evidence concerning l...
TELEMEDICINE
Increasing the Delivery Of Acute Stroke Intervention
THANK YOU!!!
THE SOLITAIRE DEVICE
SWIFT
Results from the SWIFT (Solitaire with the intention for
thrombectomy) study show that the Solitaire FR
revascularis...
Other SWIFT Findings
• Two per cent of Solitaire-treated patients had symptoms of
bleeding in the brain, compared with 11%...
NO MERCY FOR MERCI
“We are going from our first generation of clot-
removing procedures, which were only
moderately good i...
ICD:The Wingspan System: Everyone Just Got Stent
Happy
SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial
Arterial Stenosis
Patients who had a recent transien...
1. Aggressive medical management plus percutaneous
transluminal angioplasty and stenting (Wingspan stent system )
2. Contr...
The WARCEF Trial
• Coumadin or ASA for Cardiomyopathy
(WARCEF Trial- Warfarin VS Aspirin on Patients
With Reduced Cardiac ...
STROKE PREVENTION
• Nothing Beats Aggressive Medical
Management for Stroke Prevention!!
What Is It Exactly??
Stroke Prevention for Patients with Reduced
Ejection Fraction
WARCEF PRIMARY ENDPOINT
End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio
(95% CI)
p
Death, ischemic
stroke or
intra...
WARCEF: PRIMARY OUTCOME
COMPONENTS
End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio
(95% CI)
p
Death
Ischemic
strok...
WARCEF answers an important clinical question.
It's a conundrum that we face every day between
cardiology and neurology, w...
INTRACEREBRAL HEMORRHAGE WITH
INTRAVENTRICULAR EXTENSION
THE ROLE OF
INTRAVENTICULAR TPA
AND MY VERY OWN
INTRAVENTRICULAR
...
Empirical characteristics of litigation involving TPA and
ischemic stroke.
CONCLUSION:
The available evidence concerning l...
TELEMEDICINE
Increasing the Delivery Of Acute Stroke Intervention
THANK YOU!!!
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist,  Stroke Subspecialist; DIPLOMAT...
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THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist, Stroke Subspecialist; DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

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A CONCISE OVERVIEW OF THE LATEST IN STROKE EPIDEMIOLOGY, ACUTE INTERVENTION AND PREVENTIVE MANAGEMENT

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THE LATEST IN STROKE MANAGEMENT, ACUTE AND PREVENTIVE By Arlyn Valencia, M.D. Neurologist, Stroke Subspecialist; DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

  1. 1. STROKE POTPOURRI Very Recent Advances In Stroke Management Arlyn Valencia, M.D. Neurologist, Stroke Subspecialist Diplomate, American Board Of Psychiatry And Neurology
  2. 2. STROKE IS TREATABLE!!!!
  3. 3. America's Stroke Burden Someone in the United States has a stroke every 40 seconds. Every four minutes someone dies of stroke. 795,000 people in the United States have a stroke. About 610,000 of these are first or new strokes. About 185,000 people who survive a stroke go on to have another. Ischemic strokes, which occur when blood clots block the blood vessels to the brain, are the most common type of stroke, representing about 87% of all strokes. In 2010, stroke cost the United States an estimated $53.9 billion. This total includes the cost of health care services, medications, and missed days of work. Stroke is a leading cause of serious long-term disability.
  4. 4. POTPOURRI OF LATEST ADVANCES AND KNOWLEDGE IN STROKE MANAGEMENT • Acute Stroke Intervention 1. Intravenous and Intrarterial TPA 2. Intraarterial Clot Retrieval 3. Cerebral Stenting And Angioplasty During the Acute Phase
  5. 5. THE COAGULATION CASCADE
  6. 6. Intravenous rt-PA is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A). rt-PA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). AHA/ASA Guideline Recommendations
  7. 7. Intravenous fibrinolysis with rt-PA within 3 and 4.5 h was also shown to be safe in large European observational study (SITS-ISTR) which included over 650 patients treated in that time window (Wahlgren et al., 2008a). Therefore, intravenous rt-PA should be considered for selected patients with symptom duration between 3 and 4.5 h. THE TPA 4 ½ HOUR WINDOW
  8. 8. Population Not Studied Additional "exclusion criteria" for the 3–4.5 h time window" 1. Age >80 years 2. Very severe deficits at onset (NIHSS >25) 3. Combination of history of previous stroke and diabetes mellitus, and oral anticoagulation regardless of INR at presentation.
  9. 9. NINDS TPA Stroke Trial Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit Excellent outcome at 3 months on all scales 52 % 38 % 43 % 26 % 45 % 31 % 34 % 21 % 0% 10% 20% 30% 40% 50% 60% Barthel Index Rankin Scale Glasgow Outcome NIHSS score TPA Placebo N Engl J Med 1995;333:1581-7
  10. 10. NINDS TPA Stroke Trial Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit Excellent outcome at 3 months on all scales 52 % 38 % 43 % 26 % 45 % 31 % 34 % 21 % 0% 10% 20% 30% 40% 50% 60% Barthel Index Rankin Scale Glasgow Outcome NIHSS score TPA Placebo N Engl J Med 1995;333:1581-7
  11. 11. Door to IV TPA Goal ≤ 60 Minutes = Time is Brain • STARS Registry • 38 community, 18 academic hospitals, 389 IV TPA pts • Median door to needle time: 96 minutes • CDC 4 State Pilot Acute Stroke Registry • 98 hospitals, 6867 acute patients, 118 IV TPA • Treatment within target 60 minutes: 14.4% Stroke Onset to IV TPA ≤ 3 hours or ≤ 4.5 hours
  12. 12. NEUROIMAGING MODALITIES CT SCAN
  13. 13. CEREBRAL PERFUSION IMAGING A 64-year-old man presenting with headache and acute aphasia. A. NCCT shows no evidence of acute infarction. B. CT perfusion CBF map shows a region of decreased perfusion within the posterior segment of the left MCA territory (arrows). C. CBV map demonstrates no abnormality D, MTT map shows a corresponding prolongation within this same region (arrows). Therefore, representing a CBV/MTT mismatch or ischemic penumbra.
  14. 14. CTA and MRA
  15. 15. CONVENTIONAL ANGIOGRAPHY
  16. 16. CAROTID DUPLEX
  17. 17. Acute Stroke Intervention 1. Intravenous and Intrarterial TPA 2. Intraarterial Clot Retrieval 3. Cerebral Stenting And Angioplasty During the Acute Phase
  18. 18. The Dreaded DENSE MCA SIGN
  19. 19. Massive Cerebral Edema with Midline Shift and Brainstem Compression
  20. 20. Combined Intravenous and Intra-Arterial r-TPA Therapy of Acute Ischemic Stroke Emergency Management of Stroke (EMS) Bridging Trial
  21. 21. CAROTID ENDARTERECTOMY
  22. 22. THROMBECTOMY
  23. 23. MECHANICAL CLOT RETRIEVAL Mechanical thrombectomy after IV tPA seems as safe as mechanical thrombectomy alone. Mechanical thrombectomy with both first- and second-generation Merci devices is efficacious in opening intracranial vessels during acute ischemic stroke in patients who are either ineligible for IV fibrinolytic therapy or have failed IV fibrinolytic therapy.
  24. 24. THE MERCI DEVICE The device was initially approved in August 2004 and is currently labeled under the following indication: "To restore blood flow in the neurovasculature by removing thrombus in patients experiencing ischemic stroke. Patients who are ineligible for treatment with IV-rtPA or who fail IV-rtPA therapy are candidates for treatment." It consists of a flexible tapered nitinol wire with 5 helical loops that can be threaded in the thrombus for retrieval.
  25. 25. The MERCI RETRIEVER
  26. 26. THE SOLITAIRE DEVICE
  27. 27. SWIFT Results from the SWIFT (Solitaire with the intention for thrombectomy) study show that the Solitaire FR revascularisation device (ev3 / Covidien) opened blocked vessels without causing symptomatic bleeding in or around the brain in 61% of patients, compared to 24% of cases performed with the FDA-approved Merci retrieval system (Concentric Medical / Stryker). The Solitaire cerebral revascularisation device is recently approved by the FDA in the USA as of March 5, 2012!!!!!
  28. 28. Other SWIFT Findings • Two per cent of Solitaire-treated patients had symptoms of bleeding in the brain, compared with 11% of Merci patients. • At the 90-day follow-up, overall adverse event rates, including bleeding in the brain, were similar for the two devices. • Fifty eight per cent of Solitaire-treated patients had good mental/motor functioning at 90 days, compared with 33% of Merci patients. • The Solitare device also opened more vessels when used as the first treatment approach, necessitating fewer subsequent attempts with other devices or drugs.
  29. 29. NO MERCY FOR MERCI “We are going from our first generation of clot- removing procedures, which were only moderately good in reopening target arteries, to now having a highly effective tool. This really is a game-changing result.”
  30. 30. ICD:The Wingspan System: Everyone Just Got Stent Happy
  31. 31. SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis Patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery
  32. 32. 1. Aggressive medical management plus percutaneous transluminal angioplasty and stenting (Wingspan stent system ) 2. Control treatment Aggressive medical management alone 1. Aspirin, at a dose of 325 mg per day; clopidogrel, at a dose of 75 mg per day for 90 days after enrollment 2. Management of the primary risk factors a.Elevated systolic blood pressure b.Elevated low-density lipoprotein [LDL] cholesterol levels) c.Management of secondary risk factors (diabetes, elevated non–high- density lipoprotein [non-HDL] cholesterol levels, smoking, excess weight, and insufficient exercise) SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
  33. 33. STROKE PREVENTION • Nothing Beats Aggressive Medical Management for Stroke Prevention!! What Is It Exactly??
  34. 34. The WARCEF Trial • Coumadin or ASA for Cardiomyopathy (WARCEF Trial- Warfarin VS Aspirin on Patients With Reduced Cardiac Ejection Fraction)
  35. 35. Stroke Prevention for Patients with Reduced Ejection Fraction
  36. 36. WARCEF PRIMARY ENDPOINT End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio (95% CI) p Death, ischemic stroke or intracerebral hemorrhage 320 (7.93) 302 (7.47) 0.93 (O,79-1.10) 0.40
  37. 37. WARCEF: PRIMARY OUTCOME COMPONENTS End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio (95% CI) p Death Ischemic stroke Intracerebral hemorrhage 263 (6.52) 55 (1.36) 2 (0.05) 268 (6.63) 29 (0.72) 5 (0.12) 1.01 (0.85-1.21) 0.52 (0.33-0.82) 2.22 (0.43- 11.66) 0.91 0.005 0.35
  38. 38. WARCEF answers an important clinical question. It's a conundrum that we face every day between cardiology and neurology, which is, should those patients be anticoagulated long term to prevent cardioembolic strokes and other vascular events, or do they do okay on aspirin? It's a negative study with some intriguing subgroups. However, given there is no difference, aspirin should be given , because it's safer to use, easier to use, patients tolerate it pretty well, there are no food interactions, and it's inexpensive.
  39. 39. INTRACEREBRAL HEMORRHAGE WITH INTRAVENTRICULAR EXTENSION THE ROLE OF INTRAVENTICULAR TPA AND MY VERY OWN INTRAVENTRICULAR LAVAGE TECHNIQUE :)
  40. 40. Empirical characteristics of litigation involving TPA and ischemic stroke. CONCLUSION: The available evidence concerning litigation involving stroke therapy with tPA indicates liability is predominantly associated with failure to provide tPA, rather than adverse events associated with its use Annals of Emergency Medicine,2008 Aug;52(2):160-4. Epub 2008 Mar 7.Institute of Health Law Studies, California Western School of Law, San Diego Center for Patient Safety, UCSD School of Medicine, 350 Cedar Street, San Diego, CA 92101, USA
  41. 41. TELEMEDICINE Increasing the Delivery Of Acute Stroke Intervention
  42. 42. THANK YOU!!!
  43. 43. THE SOLITAIRE DEVICE
  44. 44. SWIFT Results from the SWIFT (Solitaire with the intention for thrombectomy) study show that the Solitaire FR revascularisation device (ev3 / Covidien) opened blocked vessels without causing symptomatic bleeding in or around the brain in 61% of patients, compared to 24% of cases performed with the FDA-approved Merci retrieval system (Concentric Medical / Stryker). The Solitaire cerebral revascularisation device is recently approved by the FDA in the USA as of March 5, 2012!!!!!
  45. 45. Other SWIFT Findings • Two per cent of Solitaire-treated patients had symptoms of bleeding in the brain, compared with 11% of Merci patients. • At the 90-day follow-up, overall adverse event rates, including bleeding in the brain, were similar for the two devices. • Fifty eight per cent of Solitaire-treated patients had good mental/motor functioning at 90 days, compared with 33% of Merci patients. • The Solitare device also opened more vessels when used as the first treatment approach, necessitating fewer subsequent attempts with other devices or drugs.
  46. 46. NO MERCY FOR MERCI “We are going from our first generation of clot- removing procedures, which were only moderately good in reopening target arteries, to now having a highly effective tool. This really is a game-changing result.”
  47. 47. ICD:The Wingspan System: Everyone Just Got Stent Happy
  48. 48. SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis Patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery
  49. 49. 1. Aggressive medical management plus percutaneous transluminal angioplasty and stenting (Wingspan stent system ) 2. Control treatment Aggressive medical management alone 1. Aspirin, at a dose of 325 mg per day; clopidogrel, at a dose of 75 mg per day for 90 days after enrollment 2. Management of the primary risk factors a.Elevated systolic blood pressure b.Elevated low-density lipoprotein [LDL] cholesterol levels) c.Management of secondary risk factors (diabetes, elevated non–high- density lipoprotein [non-HDL] cholesterol levels, smoking, excess weight, and insufficient exercise) SAMMPRIS: Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis
  50. 50. The WARCEF Trial • Coumadin or ASA for Cardiomyopathy (WARCEF Trial- Warfarin VS Aspirin on Patients With Reduced Cardiac Ejection Fraction)
  51. 51. STROKE PREVENTION • Nothing Beats Aggressive Medical Management for Stroke Prevention!! What Is It Exactly??
  52. 52. Stroke Prevention for Patients with Reduced Ejection Fraction
  53. 53. WARCEF PRIMARY ENDPOINT End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio (95% CI) p Death, ischemic stroke or intracerebral hemorrhage 320 (7.93) 302 (7.47) 0.93 (O,79-1.10) 0.40
  54. 54. WARCEF: PRIMARY OUTCOME COMPONENTS End Point Aspirin, n (%/y) Warfarin, (%/y) Hazard Ratio (95% CI) p Death Ischemic stroke Intracerebral hemorrhage 263 (6.52) 55 (1.36) 2 (0.05) 268 (6.63) 29 (0.72) 5 (0.12) 1.01 (0.85-1.21) 0.52 (0.33-0.82) 2.22 (0.43- 11.66) 0.91 0.005 0.35
  55. 55. WARCEF answers an important clinical question. It's a conundrum that we face every day between cardiology and neurology, which is, should those patients be anticoagulated long term to prevent cardioembolic strokes and other vascular events, or do they do okay on aspirin? It's a negative study with some intriguing subgroups. However, given there is no difference, aspirin should be given , because it's safer to use, easier to use, patients tolerate it pretty well, there are no food interactions, and it's inexpensive.
  56. 56. INTRACEREBRAL HEMORRHAGE WITH INTRAVENTRICULAR EXTENSION THE ROLE OF INTRAVENTICULAR TPA AND MY VERY OWN INTRAVENTRICULAR LAVAGE TECHNIQUE :)
  57. 57. Empirical characteristics of litigation involving TPA and ischemic stroke. CONCLUSION: The available evidence concerning litigation involving stroke therapy with tPA indicates liability is predominantly associated with failure to provide tPA, rather than adverse events associated with its use Annals of Emergency Medicine,2008 Aug;52(2):160-4. Epub 2008 Mar 7.Institute of Health Law Studies, California Western School of Law, San Diego Center for Patient Safety, UCSD School of Medicine, 350 Cedar Street, San Diego, CA 92101, USA
  58. 58. TELEMEDICINE Increasing the Delivery Of Acute Stroke Intervention
  59. 59. THANK YOU!!!

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