Implementing pathway for Neurointervention in Hyper acute Stroke
for Clinical and Research
Dr. Indira Natarajan
Consultant Stroke Physician
Clinical Lead for Acute Stroke TIA Services
University Hospital of North Staffordshire
Clinical Lead for Stroke – Heart and Stroke Network
Shrosphire and Staffordshire
UK National Stroke Strategy
DH National Stroke Strategy 2007, page 32.
There may be a role for interventional neuroradiology in the management of
basilar thrombosis.
Patients should have access to a stroke service with neuro-interventional
capacity.
A network approach may be required to develop an agreed protocol, so that
each stroke unit is linked to a regional neurosciences centre for emergency
review of local brain imaging- for example by electronic link- and emergency
transport (and then repatriation) of appropriate patients.
Strategic Health Authorities, through specialised commissioning
arrangements, to support the co-ordination of the availability of specialist
neuro-intensivist care including interventional neuroradiology and
neurosurgery expertise….
BASP CS views
There is a need for RCTs of endovascular treatments and UK stroke services
should recruit patients to such trials once they are open.
Endovascular treatments should not be offered routinely until evidence
from RCTs is available
Until such evidence is available treatment should be on a case by case basis
guided by agreed treatment and referral pathways
EVT should only be given in centres with agreed pathways and protocols
including A&E, the stroke service, neuro-interventionalist, ITU and
speciality nurses
Participation in national register/ International registers
Centres participating in RCTs will have to have experience in the procedure
before enrolling patients.
UHNS Acute Stroke Unit (ASU) 2001 to 2010
Outcome/Results
24 Beds
39 Beds
Integrated
working 32 Beds
Death
Ongoing Care
20
11
/1
1
20
07
/0
8
20
08
/0
9
20
09
/1
0
Home
20
05
/0
6
20
06
/0
7
20
01
/0
2
20
02
/0
3
20
03
/0
4
20
04
/0
5
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Where are we?
Regional Thrombolysis rota for 24/ 7
cover across the region ( Feb 2011)
Telemedicine ( April 2012)
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Until 2010 No clear Neurointerventional pathway
First encounter……..
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December 2009
75 year old gentleman
Recent cervical spine surgery 4 months ago
Admitted with collapse and found unconscious
GCS 4/15
Intubated and ventilated
No reversible pathology
Atrial fibrillation
CT brain Normal study
Cervical Halo
Basilar occlusion on CTA
 Discussion with Orthopaedic Surgeon/ Neuroradiologist
 Agreed for Intravenous and intra-arterial
 Anaesthetist arranged
 Whole episode was chaotic
 Since no clear pathway - theatre team difficult to coordinate
 ODA had to be pulled off from Neuro-surgical theatre
 Significant amount of time lost from arrival of patient
to A and E and before procedure commenced
Time is Brain……
Pathway for ischaemic stroke
treated with r t-PA?
999
Triaged in A and E
Within 3 - 4.5 Hrs
Neuro-interventional pathway
999
Time is Brain
The Team
Interventional
Neurorradiologist
1 Radigrapher
1 Nurse
Stroke Physician
Anaesthetist / ODA
Agreed patient group…
 Age<75
 Previously fit and well
 Working hours (out of hours if interventional
neuroradiologist available)
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Teams that we engaged
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Radiology / Neuroradiology
Anaesthetics/ ITU
Neurosurgery
Emergency Medicine
Radiology protocol
 Yellow sheet for Stroke patients
 CT brain and CT angiogram as agreed protocol
CT head scan
Order a non-contrast CT head immediately after arrival (urgent
e.g. within 1 hour) for all strokes.
[label form ACUTE STROKE call 4042 (daytime) or on call
radiologist (nights, weekends and holidays)].
Thrombolysis candidates and patients on warfarin must be
scanned immediately (within 15 min)
Order a CT angiogram (arch to Circle of Willis) if <75 y and no
contraindications to contrast and
within < 8 h of onset and no haemorrhage and no signs of established
infarction on the CT head scan.
Neuro-radiologist / Stroke
Physician alerted when
 CT angiogram findings which suggests need for IA
intervention
 Carotid T occlusion (intracranial carotid bifurcation
occlusion with involvement of A1 and M1 segments)
 M1 (trunk of the MCA) or M2 (MCA branch in Sylvian
fissure) occlusion
 Vertebro- basilar thrombosis
To get a Standard Operation
Pathway agreed for Stroke as E 1
 Emergency theatres prioritisation codes
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E1
E2
E3
E4
Immediate transfer to theatre
Within 6 hours
Within 12 hours
Urgent, but timing not critical
Potential indications for EVT
Primary intra-arterial thrombolysis
Severe disabling neurological deficit and
Contraindications to iv thrombolysis (e.g. recent surgery), 3-6 h from
symptom onset
Intravenous/ Intra-arterial /EVT
Severe disabling neurological deficit and
Large vessel occlusion in MCA
Brain stem stroke
Treatment can be delivered within 9 h of symptom onset and
Occlusion of basilar artery documented on 4-vessel angiography
Eligible even if consciousness impaired and or patient ventilated
Key paperworks……
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Consent Sheets form 1 / form 4
Patient information sheet
Theatre check list
IA log
Nursing pathway for Intervention
Time CT angio
IV alteplase given
Y / N
Time of IV alteplase bolus
Consent/assent signed
Y / N
Time of last micturition
(offer bottle & conveen)
Arrival time in cathlab
Anaesthesia
GA / LA
Start time of GA/LA
Time of femoral puncture
= start of procedure
Start time catheter angio
Catheter used for angio
IA lysis done
Y / N
Catheter used for IA lysis
Time of IA catheter at clot
Time first dose of IA tPA
Time last dose of IA tPA
Total dose of IA tPA
Total dose of IV & IA tPA
Mechanical Thrombectomy
Device used for MT
Stat time of MT
No of attempts of MT
Time of clot capture
Time of final catheter angio
= end of procedure
Time of post procedure CT (after final angio)
Time out of cathlab
Arrival time in stroke unit
Y / N
Suitable patient
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Potential patient for IAT/MT identified
Fit for GA/ thrombectomy
Previously independent
NIHSS>=10 or basilar artery thrombus
No bleed or sub acute infarct on CT head
CTA shows large vessel occlusion (ICA/M1/M2/ VA/BA/
PCA)
Lysis Protocol
 Start iv lysis while waiting for theatre. Give 0.6 mg /kg
alteplase (bolus and infusion) iv unless iv lysis is
contraindicated (recent surgery, post-partum). Leave
0.3mg/kg (max 30 mg) for i.a. lysis.
 Do CT head immediately post procedure and after 24
h.
 Stay with patient until awake and settled on stroke
unit.
 Ensure patients is monitored according to the IAT
nurse pathway.
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Pathway in action….
 Keep next of kin on site for consent /queries or
establish contact route
 Clinician (stroke physician / A&E doctor) to get an
anaesthetist STAT: neuro-anaesthetist, if possible,
otherwise on call: contact via switch
 Clinician (Stroke physician / A&E doctor) to inform
ODA
 Out of hours Arrange for an anaesthetist – go to
online services / rota watch / on call anaesthetist –
bleep 3rd on call
 Radiologist to get radiographer and scrub nurse for
the procedure. Set up operating trolley and
equipment immediately.
 Inform Stroke Unit for arranging a bed – Stroke team
Prepare the patient
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(A&E staff/ stroke team/ neurointerventionalist)
Discuss procedure
Complete consent form
Complete theatre checklist (inside the consent form)
Put patient into a theatre gown
Offer bottle or catheterize
Put in IA line (in A&E or theatre)
Transfer to neuro-interventnional theatre
Prepare for intervention
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Start the intra-arterial intervention log
Theatre team to move patient onto the
intervention table
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Theatre team to cover patient with sterile sheets
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Anaesthetist and ODA to commence local/
general anaesthesia
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Neuroradiologist or scrub nurse to clean/
disinfect groin.
During / After Intervention
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Complete intra-arterial intervention log
Remove catheter/ intra-arterial line
Liaise with ASU to alert team about patient transfer
Get a bed tracked to the intervention suite to transfer
patient to ASU
 Patients who were ventilated before the procedure
may need ITU/MIU.
Regional referral protocols….
 Devised protocols through our Heart and Stroke
Network for regional DGH’s
 Clear pathway for in hours and out of hours
 Drip and Ship with escort
 We have accepted patients outside our region on
occasions
Barriers…..
 Trust
 Commissioning
 Costing
 Getting all the teams together
Media – Not a good idea
Tuesday, February 09, 2010
Pioneering stroke drugs saved Patient
This is Staffordshire
FATHER-OF-FOUR owes his life to being at the right place at
the right time after suffering a massive stroke
.
The attack was severe enough to give him just a 20 per cent chance of surviving.
•
Costings……
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Consumables overall
£ 1600
Device cost ranges roughly around £ 4000
( prices can be negotiated depending upon trusts)
Average use of devices is around 1.5 (from our
experience of 50 cases)
 Out of hours theatre staff cost
£ 500
-------------------------------------------------------------------------------------------- Overall rough cost estimate is around £ 6100
Cost for Post Stroke Care
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Hospital Care
Basic bed day in Stroke unit: £ 170 /day
With added costs : £ 350/ day
Patients with mRs 4 and 5 average LoS: 90 days
Cost for 90 days: £ 31,500
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Social / Residential care:
mRS 5 : £550 / week ( £ 28,600/ year)
mRS 4: £ 400 - £ 450 /week ( £ 20,800 - £ 23,400/year)
mRs 3: ( if care required) : £ 300/week ( £ 15,600/year)
Funding
Primary Care Trust
NHS
Stroke Network
Stroke Fund
Intervention Fund
Neuroscience Department
Geriatric Medicine
Under discussion
2
2
1
1
1
1
1
1
HRG Coding
 Percutaneous trans-luminal embolectomy /
thrombectomy of artery:
 L 712
 HRG - QZ15 A - Major complication with comorbidities £ 9554
 HRG – Q Z15B – Minor complications £ 5098
 HRG – QZ15 C – No complications
£3731
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 On top for Alteplase: you get another 800£
Challenges
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24/ 7 Sustainability
Reliant on key individuals
Job Plan
Integrated pathway agreement with other centres
Need to demonstrate quality before taking part in
Research trials
Centres in the UK
> 1 per month
5 – 10 / 10 months
Frequency of endovascular treatments for acute ischaemic
stroke in active centres in 2010
Number of
centres
0
4
1-4
(1 every 3 mo or less)
8
5-9
(one every other month)
>=10
5
6
Capacity, organisation, and quality
control ( Nationally)
23 active centres
71 interventional Neuroradiologists in the UK in 2010
46% of centres not providing EVT had no procedures for referral to centres
providing such treatments.
56% of centres providing EVT entered patients into the SITS register
56% of centres providing EVT entered patients into the SINAP
Type of Approach
Thrombolysis pathway
Neuro-interventional pathway
In Summary
 Newer interventions needs newer pathway
 Part of expansion of Neurosciences Units
 Part of the Clinical Research activity
 One needs to start somewhere………………..
Resources
 http://www.stroke-in-stoke.info/
You can look at our:
 Pathway
 Patient Information leaflet
 Procedure log
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Nurse pathway
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Protocols
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Data entry file – We are happy to support data
Acknowledgements….
 Prof Christine Roffe
 Dr. Sanjeev Nayak
 All the Neuro-interventional team / Anaesthetic team/
ITU team / Stroke team/ Exec Board