Update in Ischemic Stroke 2004 Timothy Lukovits, M.D. Co-Director, Dartmouth Stroke Program
 
“Stroke Unit” 1960 and 2004
Stroke Care 1960 Stroke Care 2004
 
<ul><li>ACGME-approved stroke fellowships </li></ul><ul><li>ABPN subspecialty certification in stroke neurology </li></ul>
 
Expected benefits of primary stroke centers <ul><li>Improved efficiency of patient care </li></ul><ul><li>Fewer peri-strok...
Checks patient information against applicable AHA/ASA Guidelines (Stroke and CAD)
Copyright restrictions may apply. LaBresh, K. A. et al. Arch Intern Med 2004;164:203-209. Pilot data from the New England ...
Also, health departments in Mass. and NY beginning certification of stroke centers
 
 
Question 1 for the audience <ul><li>Is there a need for stroke centers? </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><...
Question 2 for the audience <ul><li>Does the benefit of t-PA outweigh the risk? </li></ul><ul><ul><li>Yes </li></ul></ul><...
 
 
 
 
 
 
 
8 years after FDA approval  and  even more controversial !
 
DWI  (Diffusion Weighted Imaging) PWI (Perfusion Weighted Imaging)
Diffusion weighted imaging Isolated weakness right index finger JS Kim, Neurology, 2002
 
“ Mismatch” =  PWI volume 20% >DWIvolume Good tPA candidate Possible tPA candidate Questionable tPA candidate
 
Amyloid angiopathy: a risk factor for warfarin and thrombolytic related ICH:
 
CT/CTA CTPerfusion PWI/DWI/MRA
 
Mechanical thrombolysis
Advantages of mechanical thrombolysis <ul><li>Decreased or no need for lytic agent </li></ul><ul><li>More rapid and effect...
Concentric Retriever device
 
FDA approval August 2004
Ultrasound-enhanced lysis
 
Carotid stenting
Carotid angioplasty and stenting: an evolving technology
 
 
 
 
 
FDA HDE for PFO closure devices
How do we apply these advances in New Hampshire? <ul><li>We have many small hospitals separated by miles, mountains and mi...
 
Stroke Medical DRGs 9/99-10/01
 
<ul><li>Hospitals that appear to have basic infrastructure to meet BAC Criteria for Primary Stroke Centers (24/7 blood stu...
American Heart Association North East Stroke Taskforce Structure   Northeast Affiliate, Health Initiatives,  Advocacy & Co...
NH stroke task force <ul><li>Timothy Lukovits, MD Dartmouth Hitchcock Medical Center </li></ul><ul><li>Donna Clark, MD Dar...
Stroke Educ. activities in NH/VT <ul><li>Concord Neurology for Primary Care November 19, 2003 </li></ul><ul><li>Concord (N...
Other Task Force Activities <ul><li>Meeting in Portsmouth, NH January 2005 </li></ul><ul><li>Encourage use of GWTG-Stroke ...
Why should we consider organizing stroke care regionally? <ul><li>Networking will improve use of limited resources </li></...
CASES
Case 1
A 49 yo male was evaluated because of sudden left-sided numbness and weakness.  Two weeks prior to my evaluation, he devel...
 
 
Small filling defect (?embolus) in the mid to distal left pericallosal artery.
 
3 x 3 cm pulmonary AVM in the left lower lobe.
 
Case 2
 
 
Case 3
C onfused  V ascular A nalyses We need to prevent CVAs!
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    1. 1. Update in Ischemic Stroke 2004 Timothy Lukovits, M.D. Co-Director, Dartmouth Stroke Program
    2. 3. “Stroke Unit” 1960 and 2004
    3. 4. Stroke Care 1960 Stroke Care 2004
    4. 6. <ul><li>ACGME-approved stroke fellowships </li></ul><ul><li>ABPN subspecialty certification in stroke neurology </li></ul>
    5. 8. Expected benefits of primary stroke centers <ul><li>Improved efficiency of patient care </li></ul><ul><li>Fewer peri-stroke complications </li></ul><ul><li>Increased use of acute stroke therapies </li></ul><ul><li>Reduced morbidity and mortality </li></ul><ul><li>Improved long-term outcomes </li></ul><ul><li>Reduced costs </li></ul><ul><li>Increased patient satisfaction </li></ul>
    6. 9. Checks patient information against applicable AHA/ASA Guidelines (Stroke and CAD)
    7. 10. Copyright restrictions may apply. LaBresh, K. A. et al. Arch Intern Med 2004;164:203-209. Pilot data from the New England Get With the Guidelines program (12-month results)
    8. 11. Also, health departments in Mass. and NY beginning certification of stroke centers
    9. 14. Question 1 for the audience <ul><li>Is there a need for stroke centers? </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>No </li></ul></ul>
    10. 15. Question 2 for the audience <ul><li>Does the benefit of t-PA outweigh the risk? </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>No </li></ul></ul>
    11. 23. 8 years after FDA approval and even more controversial !
    12. 25. DWI (Diffusion Weighted Imaging) PWI (Perfusion Weighted Imaging)
    13. 26. Diffusion weighted imaging Isolated weakness right index finger JS Kim, Neurology, 2002
    14. 28. “ Mismatch” = PWI volume 20% >DWIvolume Good tPA candidate Possible tPA candidate Questionable tPA candidate
    15. 30. Amyloid angiopathy: a risk factor for warfarin and thrombolytic related ICH:
    16. 32. CT/CTA CTPerfusion PWI/DWI/MRA
    17. 34. Mechanical thrombolysis
    18. 35. Advantages of mechanical thrombolysis <ul><li>Decreased or no need for lytic agent </li></ul><ul><li>More rapid and effective clot disruption </li></ul>
    19. 36. Concentric Retriever device
    20. 38. FDA approval August 2004
    21. 39. Ultrasound-enhanced lysis
    22. 41. Carotid stenting
    23. 42. Carotid angioplasty and stenting: an evolving technology
    24. 48. FDA HDE for PFO closure devices
    25. 49. How do we apply these advances in New Hampshire? <ul><li>We have many small hospitals separated by miles, mountains and misgivings? </li></ul><ul><li>Limited interest or resources in stroke </li></ul>
    26. 51. Stroke Medical DRGs 9/99-10/01
    27. 53. <ul><li>Hospitals that appear to have basic infrastructure to meet BAC Criteria for Primary Stroke Centers (24/7 blood studies, Stroke QI program, ED, Stroke Care map, t-PA protocol, prewritten stroke orders): </li></ul><ul><li>3 </li></ul>
    28. 54. American Heart Association North East Stroke Taskforce Structure Northeast Affiliate, Health Initiatives, Advocacy & Communications Committee ME Stroke Taskforce NH Stroke Taskforce RI Stroke Taskforce VT Stroke Taskforce North East Stroke Taskforce (NEST) Chairperson, Lee Schwamm, MD MA Stroke Taskforce Upstate NY Stroke Taskforces: Albany, Buffalo & Syracuse AHA/ASA “Local Market” Stroke Taskforces Rev. 6/30/04
    29. 55. NH stroke task force <ul><li>Timothy Lukovits, MD Dartmouth Hitchcock Medical Center </li></ul><ul><li>Donna Clark, MD Dartmouth Hitchcock Medical Center </li></ul><ul><li>Jonathan Friedman, M.D. Dartmouth Hitchcock Medical Center </li></ul><ul><li>Robert Zwolak, M.D. Dartmouth Hitchcock Medical Center </li></ul><ul><li>Parker Towle, M.D. Dartmouth Hitchcock Medical Center </li></ul><ul><li>Sarah Johansen, MD Dartmouth Hitchcock Medical Center </li></ul><ul><li>Wendi Guillette, OTR/L Healthsouth Rehabilitation Hospital </li></ul><ul><li>Elva Hawkins, RN Elliot Hospital </li></ul><ul><li>David Hogarty, MD Healthsouth Rehabilitation Hospital </li></ul><ul><li>Patricia Locuratolo, MD Neurologist - Portsmouth </li></ul><ul><li>Douglas Black, MD Neurologist - Portsmouth </li></ul><ul><li>Archie McGowan, MD Portsmouth Radiological Associates, PA </li></ul><ul><li>Rachel Rowe Foundation for Healthy Communities </li></ul><ul><li>Sue Prentiss NH EMS </li></ul><ul><li>Powen Hsu New Era Medicine </li></ul><ul><li>Craig Day AHA/ ECC Manager – ME, NH, VT </li></ul><ul><li>Nancy Pederzini AHA/ Advocacy Director – NH </li></ul>
    30. 56. Stroke Educ. activities in NH/VT <ul><li>Concord Neurology for Primary Care November 19, 2003 </li></ul><ul><li>Concord (NH Brain Injury Assoc. Meeting) November 19, 2003 </li></ul><ul><li>DHMC Rehab Conference March 2, 2004 </li></ul><ul><li>DHMC Rehab Conference March 9, 2004 </li></ul><ul><li>New London May 3, 2004 </li></ul><ul><li>Berlin (AVH) May 18, 2004 </li></ul><ul><li>Nashua (Southern NH Medical Center) June 24, 2004 </li></ul><ul><li>Concord Neurology for Primary Care November 10, 2004 </li></ul><ul><li>NH Medical Society November 10, 2004 </li></ul><ul><li>Huggins Hospital (NH Emergency Medicine) November 18, 2004 </li></ul><ul><li>DHMC Cardiology Conference December 6, 2004 </li></ul><ul><li>Woodsville (Cottage) December 21, 2004 </li></ul><ul><li>Elliot Hospital January 20, 2005 </li></ul><ul><li>Norwich, VT EMTs January 5, 2004 </li></ul><ul><li>Woodstock, VT Primary Care Neurology Conference February 25, 2004 </li></ul><ul><li>Stowe, VT Northern New England Neurology Conference February 26, 2004 </li></ul><ul><li>Bennington, VT (Southwestern VT Medical Center) September 11, 2004 </li></ul>
    31. 57. Other Task Force Activities <ul><li>Meeting in Portsmouth, NH January 2005 </li></ul><ul><li>Encourage use of GWTG-Stroke and Primary Stroke Center concept </li></ul>
    32. 58. Why should we consider organizing stroke care regionally? <ul><li>Networking will improve use of limited resources </li></ul><ul><ul><li>We can share continuing education activities </li></ul></ul><ul><ul><li>We can share limited diagnostic and therapeutic resources (e.g., subspecialty cerebrovascular disease care for complicated cases) </li></ul></ul><ul><ul><li>Imagine a new revolutionary treatment becomes available </li></ul></ul><ul><ul><li>Improved patient access to clinical studies </li></ul></ul><ul><ul><li>We can learn from and be stimulated by each others’ experiences and enthusiasm </li></ul></ul>
    33. 59. CASES
    34. 60. Case 1
    35. 61. A 49 yo male was evaluated because of sudden left-sided numbness and weakness. Two weeks prior to my evaluation, he developed sudden numbness of the left arm and leg and he had difficulty moving the arm but he was able to drive his truck a short distance. He was evaluated at a small community hospital and his symptoms improved over the next couple of days. He had an MRI and was told it was normal and was discharged with a diagnosis of “neurologic migraine or RIND”. This caused confusion because he still had a sense of numbness and heaviness in the left arm and he felt like his thought processes were slowed. On examination, I found that he had mild weakness of the left arm and leg and some psychomotor slowing.
    36. 64. Small filling defect (?embolus) in the mid to distal left pericallosal artery.
    37. 66. 3 x 3 cm pulmonary AVM in the left lower lobe.
    38. 68. Case 2
    39. 71. Case 3
    40. 72. C onfused V ascular A nalyses We need to prevent CVAs!
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