Neuroscience
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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Chapters
Summary January 18th, 2018
The outcome of patients with acute ischemic stroke depends on swift restoration of cerebral blood flow. This protocol aims at optimizing the management of such patients by minimizing peri-procedural timings and rendering the time from hospital admission to reperfusion as short as possible.
Transcript
The overall goal of this procedure is to optimize the management of patients with acute ischemic stroke, by rendering the time from hospital admission to restoration of cerebral blood flow as short as possible. This method can help answer key questions in the stroke management field, such as minimizing per procedural timings and acute ischemic stroke with a streamline workflow and interdisciplinary teamwork. The main advantage of this technique is that a one-stop management approach, including diagnostic imaging, and subsequent treatment in the end just significantly reduces doctorate perfusion times We first had the idea for this method after publication of the negative endoverse thrombectomy trials in 2013.
Entrys for the time delay was one of the obvious reasons for the negative results. Interdisciplinary teamwork and communication between neurologists, neuroradiologists, and anesthesiologists are very important for the success of this procedure. Regular team meetings and trainings should be held to maintain good performance.
First, inform the neuroradiologist that a patient with signs suggestive of acute stroke is expected prior to the arrival of the patient. State the age and symptom on set if known. Also, have the neuroradiologist inform the interventional neuroradiologist about a suspected upcoming acute stroke patient.
Furthermore, inform the anesthesiologist about the potential upcoming endovascular treatment, or EVT. Perform a rapid clinical assessment of the patient upon arrival, including the quantification of functional impairment, according to the NIHSS. Thus, test the level of consciousness, vision, motor and sensory function, language and speech, as well as extinction and inattention.
Meanwhile, have the ER nurse place two large peripheral venous catheters and take a blood sample for immediate laboratory analysis. Next, have the ER nurse attach ECG, blood pressure, and blood oxygen saturation mobile monitoring systems to the patient. If stroke is suspected, choose whether to follow scenario a or scenario b, based on the NIHSS score and time from symptom onset to admission.
Obtain a backpack containing emergency equipment and a complete set for entravenous thrombolysis. Include 90 milligrams RTPA, syringes, IV, lines, and a syringe pump in the set. Escort the patient to the angiography suite for scenario a, as demonstrated in this video.
Alternatively, escort the patient to the CT imaging site, adjacent to the angiography suite for scenario b, as described in the text protocol. If the NIHSS is seven or above, and less than six hours have elapsed since symptom onset, perform diagnostic imaging and scenario a. Position the patient on the angiographic table together with the neurologists and the neuroradiological technician.
Position the patient's head within the head holder, so that the orbitomeatal line is parallel to the rotation plane. Cover the eyes, and fixate the head with two straps to prevent motion. Prepare a standard 20-second non-enhanced rotational flat-panel detector computed tomography, or FDCT.
Perform FDCT on the angiography system, using a 20-second rotation, a 200 degree total angle with approximately 500 projections, 109 kilovolts, 1.8 micrograys per frame, and an effective dose of approximately 2.5 millisiverts. Next, prepare for a standard biophasic FDCT angiography, or FDCTA, through intravenous injection of 60 milliliters contrast agent at an injection rate of five milliliters per second, followed by a 60-milliliter saline chaser at the same injection rate of five milliliters per second. Use the antecubital vein of the right arm in order to optimize the bolus concentration;use a power injector for injection.
Perform FDCTA, using two 10-second rotations, 200 degrees total angle, 70 kilovolts, 1.2 micrograys per frame, and an effective dose of approximately 2.5 millisieverts. Review the acquired images together with the interventional neuroradiologist to rule out an intracranial hemorrhage, using the FDCT, and to detect LVO using the early phase of the FDCTA. Use the late venous phase of the FDCTA to evaluate the collateral status.
The reliable exclusion of amoragic stroke is crucial. A neuroradiologist with experience in evaluating FDCT images should carefully review the images and ultimately clear the patient for administration of RTPA, and for EVT. After exclusion of an intracranial hemorrhage, and confirmation of patient's eligibility, have the neurologist start intravenous administration of RTPA.
Call the anesthesiologist and confirm an upcoming EVT. Have mobile monitoring devices placed by stationary devices present in the angiography suite, and start preparations for EVT immediately. Prepare the patient for the EVT, together with the neuroradiological technician.
Have the neuroradiological technician set up the material required for the EVT. Shave and disinfect the patient's groin with skin-antiseptic, and place sterile drapes to insure aseptic conditions for the EVT. Induce sedation with ketamine, in combination with propofol, intravenously, and maintain a continuous infusion of propofol to insure sufficient spontaneous breathing and patient cooperation.
If conscious sedation seems inappropriate due to sustained agitation or movement of the patient, intubate the patient so that EVT is performed under general anesthesia. To perform the EVT, puncture the right femoral artery in the groin, using an 18-gauge puncture needle, and introduce a peripheral, 8F guiding sheath. Then, start the EVT.
The total target time from patient admission to groin puncture is 30 minutes. Confirm successful reperfusion, which is defined as a modified thrombolysis in cerebral infarction score of 2b to three from control angiogram. Then, perform a flat panel detector angiographics CT.Read the images to rule out complications of the treatment, such as intracranial hemorrhage.
Representative median times for individual steps between symptom onset and reperfusion are shown before and after introduction of the SOP. The revised version includes the one-stop management approach demonstrated in the video. Notably, the median time from hospital admission to groin puncture was reduced after implementation of the first version of the SOP.
The revision of the SOP, including the one-stop management approach, led to a further reduction of this median time. Once mastered, this procedure can be done in 60 minutes, if it is performed properly. While attempting this procedure, it's important to remember that the proposed one-stop management approach is limited to hospitals equipped with the latest generation angiography suite, and with staff experienced in interpretation of FDCT and FDCTA always available.
This procedure is tainted to the conditions of our hospital. However, we think that the similar approach can be implemented in other hospitals, despite structural differences. After watching this video, you should have a good understanding of how to implement a one-stop management approach to shorten doctor perfusion times for acute stroke patients.
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