Code Stroke in Pandemic Era - IDI

Dr. Mohammad Kurniawan, MSc (stroke med.), FICADept. Neurology Faculty of Medicine, Universitas Indonesia

Cipto Mangunkusumo National Hospital

Code Stroke in Pandemic Era

STROKE An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction/ischemia, based on pathological, imaging, or other objective evidence in a defined vascular distribution; and/or clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded

(AHA/ASA Expert Consensus 2013)

EPIDEMIOLOGY

1 in 4 of uswill have a stroke

Every 2 second, there will be 1 person suffered from stroke

• Penyebab kematian No. 2 di dunia

• Penyebab kematian No. 1 di Indonesia

• Setiap 10 detik, 1 orang meninggal akibat strokeKematian

• Penyebab kecacatan No. 1 di dunia

• Penyebab kecacatan No. 1 di Indonesia

• 63,7% orang tua pasca stroke di Indonesia tidak bisahidup tanpa bantuan (akibat kecacatan)

Kecacatan

• Beban ekonomi 53.6 miliar USD (Rp 750 T)/tahun

• Termasuk 4 besar penyakit dengan biaya tertinggimenurut data BPJS (Rp 1.62 triliun)

• Meningkat 37% setiap tahun

DampakEkonomi

Time is Brain, every minute counts

Blockage of one blood vessel will cause ischemia

Saver JL, Stroke 2006

STROKE

Time lost is Brain lost

TimeNeurons

LostSynapses

LostMyelinated Fibers Lost

Premature Aging

1 second 32,000 230 million 200 m 8.7 hours

1 minute 1.9 million 14 billion 12 km 3.1 weeks

1 hour 120 million 830 billion 714 km 3.6 years

Complete 1.2 billion 8.3 trillion 7140 km 36 years

Stroke is Emergency Time is Brain Tissue

Saver. Stroke 2006;37:263-266.González. Am J Neuroradiol 2006;27:728-735.

Donnan. Lancet Neurol 2002;1:417-425.

An untreated patient

loses approximately 1.9

million neurons every

minute in the ischaemic

area

Revascularization /

reperfusion offers the

potential to reduce the

extent of ischaemic injury

Ischaemic core

(brain tissue

destined to die)

Penumbra

(salvageable

brain area)

FAILED TO UNDERSTAND…

Intravenous thrombolysis (NNT : 3.6 to 5.9)Mechanical thrombectomy (NNT : 2.6/5)Intra-arterial thrombolysis (NNT : 7.7)

Goal : Recanalization - Reperfusion

Code Stroke

A term used to prioritize the hyperacute assessment and care of a patient presenting

with signs and symptoms concerning for stroke.

The word code brings forward a sense of nuance with measured urgency without

compromising precision in diagnosing and treating patients with stroke.

Intravenous Thrombolysis

Endovascular treatment with Mechanical Thrombectomy

Intravenous Thrombolysis (IVT)

Stroke Thrombolysis Evidences

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

ECASS 3 - EndpointsDay 90: NINDS global endpoint statistic

(mRS 0-1; BI ≥95; NIHSS ≤1 or >8 point improvement; GOS 1)

Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.

rt-PA

(N=418)

Placebo

(N=403)

OR

(95% CI)

p

Global outcome n/a n/a 1.28

(1.00–1.65)

0.05

mRS score ≤1 219 (52.4%) 182 (45.2%) 1.34

(1.02–1.76)

0.04‡

BI score ≥95 265 (63.4%) 236 (58.6%) 1.23

(0.93–1.62)

0.16‡

NIHSS score ≤1 210 (50.2%) 174 (43.2%) 1.33

(1.01–1.75)

0.04‡

GOS score 1 213 ( 51.0%) 183 (45.4%) 1.25

(0.95–1.64)

0.11‡

0.5 1 1.5

Favours placebo Favours rt-PAITT, intent-to-treat; ‡ p value was obtained by

the Pearson chi-square test of proportions

NNT to Reach Optimal Benefit from IV TPA

(mRS 0-1)

Hacke W et al. Lancet 2004 ; Lees KR et al. Lancet 2010

Evidence - Based Guidelines of StrokeThrombolysis

I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose given as a

bolus followed by a 60-minute infusion, is recommended within 4.5 hours of

onset of ischaemic stroke (Class I, Level A)

ESO Guidelines 2021

Intravenous rt-PA is recommended for selected patients who may be treated

within 3 hours of onset of ischemic stroke (Class I Level 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 Level B)

AHA/ASA Guideline 2019

Alteplase direkomendasikan pada Stroke iskemik, onset pemberian trombolisis

direkomedasikan ialah ≤4,5 jam atau ≤6 jam (bukan wake up stroke) pada jalur

intravena dengan sirkulasi anterior

(PNPK Stroke 2019)

Recommendation Regarding Thrombolytic Treatment in Acute Ischemic Stroke

▪ An organized protocol for the emergency evaluation of patient with suspected stroke is reccommended (I/B)

▪ It is recommended that DTN time goals be established. A primary goal of achieving DTN times within 60 minutes in ≥50% of AIS patients treated with IV alteplase should be established (I/B)

▪ It may be reasonable to establish a secondary DTN time goal of achieving DTN times within 45 minutes in ≥50% of patients with AIS who were treated with IV alteplase (Iib/C)

▪ Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is recommended. Patients with stroke should have a careful clinical assessment, including neurological examination (I/A)

▪ Multicomponent quality improvement initiatives, which include ED education and multidisciplinary teams with access to neurological expertise, are recommended to safely increase IV thrombolytic treatment (I/B)

AHA/ASA Guideline Guidelines for the Early Management of Patients With Acute Ischemic Stroke 2019

Early Management of Patients With Acute Ischemic Stroke HOSPITAL STROKE TEAMS

NIH-Recommended ED Response Time

NINDS NIH website. Stroke proceedings. Latest update 2008

DTN ≤60 min : the “golden hour” for evaluating & treating acute stroke

T=0

Suspected

stroke patient

arrives at

stroke unit

≤10 min

Initial MD evaluation

(including patient

history, lab work

initiation, & NIHSS)

≤ 15 min

Stroke team

notified

(including

neurologic

expertise)

≤ 25 min

CT scan

initiated

≤ 45 min

CT & labs

interpreted

≤ 60 min

rt-PA

given if

patient

is eligible

THROMBOLYSIS PATHWAY

➊ Arrival to ED

➋ A&PE assessment

➌ Stroke team notified

➍ Order priority CT Brain

➎ Lab & ECG exams

➏ CT scan performed

➐ CT report obtained

➑ Patient informed and consent

obtained

➒ Reconstitution and drawing up of

Alteplase

➓ Thrombolysis is initiated

INCLUSION CRITERIA

1. Clinical signs and symptoms of definite acute stroke

2. Clear time of onset

3. Presentation within 3 hrs of acute onset

4. Haemorrhage excluded by CT scan

5. Age 18 - 80 years old

6. Consent to treat (every effort must be made to contact next of kin)

EXCLUSION CRITERIA1. Rapidly improving or minor stroke symptoms (NIHSS 1-4)

2. NIHSS < 5 or >25

3. Stroke or serious head injury within 3 months

4. Major surgery, obstetrical delivery, external heart massage in last 14 days

5. Seizure at onset of stroke

6. Prior stroke and concomitant diabetes

7. Severe haemorrhage in last 21 days

8. Increase bleeding risk

9. History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy)

10. Blood pressure above 185 mmHg systolic or 110 mmHg diastolic

11. Symptoms suggestive of SAH (even if CT is normal)

12. Known clotting disorder

13. APTT abnormal, INR>1.5

14. Suspected iron deficient anaemia

15. Thrombocytopenia <100,000

16. Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL

17. Bacterial endocarditis, pericarditis

18. Acute pancreatitis

19. Ulcerative GI disease in last 3 months, oesophageal varices, arterial-aneurysm, arterial/venous malformation.

20. Severe liver disease including cirrhosis, acute hepatitis

DTN

The Golden Hour

Pasien dicurigaiStroke

DOKTER EMERGENSICURIGA STROKE AKUT < 4.5 jam)

Gejala FAST : (Lihat Ceklis)

-Face (mulut mencong)-Arm (lemah separuh badan)-Speech (pelo/afasia)-Time last normal (< 4.5 jam)

Dalam 10 menit :1. EKG2. GDS (stick)3. Lab (bila perlu)

(Warfarin → INR ; NOAC → APTT)4. Order Urgent CT/MRI Brain 5. Nilai NIHSS6. Pasang iv-line7. Call Neurologist

DPJP NEUROLOGI

Konsul / Refer cito ! Neurologi

• IGD (Triage)• Ruang Rawat

ACTIVATE CODE STROKE

DPJP Neurologi• Konfirmasi Stroke Iskemik• Klarifikasi onset gejala• NIHSS• Order Obat Alteplase

UrgentCT/MRI Brain

ELIGIBILITAS TROMBOLISISLihat Ceklis

START TROMBOLISIS

TRANSFER KE RUANGAN (STROKE UNIT/HCU/ICU)

•Dosis Alteplase 0.6-0.9 mg/kgBB• Berikan bolus 10% dosis• Sisanya di drip dalam 1 jam

CO

DE

STR

OK

E R

SCM

/FK

UI

DN

T: 6

0 M

inu

tes

TROMBEKTOMI @CATHLAB

Mechanical Thrombectomy(Endovascular Thrombectomy/EVT) in Acute Ischemic Stroke

History of EVT in Hyperacute Ischemic Stroke

Local intra-arterial thrombolysis1988 - 1998

Terapi intervensi endovaskular

• Pemberian rtPA (Alteplase) harus dilakukan secepatnya pada pasien yang memenuhi kriteria (kelas I, peringkat bukti A).

• Pasien sebaiknya mendapatkan terapi endovaskular dengan menggunakanstent retriever jika memenuhi kriteria sebagai berikut (kelas I, peringkatbukti A):

a) Skor mRS prestroke 0 sampai 1b) Stroke disebabkan karena oklusi pada arteri karotis interna atau arteri serebri media

cabang proksimal.c) Usia ≥18 tahun.d) Terapi dapat dimulai (puncture) dalam 6 jam setelah onset stroke.e) Skor NIHSS ≥6.f) Skor ASPECTS ≥6.

Sharing our experience…

IVT & EVT : ‘time-critical, multimodal emergency treatment’

First vial of Alteplase

Given in RSCM, Indonesia

1995 1999 2003 2005 2008 2009 2012 2013 2014 2015 2017

First Thrombectomy

in RSCM

• Increased daily patient visit since the deliberation of Universal Health Coverage (JKN)

• ‘Onset to Door’ getting faster

• CODE STROKE was proposed in 2014 to catch up with level 1 evidence worldwide

acute stroke service

What we have achieved…

≤ 60 mins

Door to Needle≤ 25 mins

Door to CT

>40 casesThrombectomy

since Jan 2017

≤420

minsOnset to Puncture

CODE STROKEWarning system for integrated-team trained residents, fellows, nurses,

pharmacy, administration, & stroke team (neurologist, neurosurgeon,

neurointerventionist & radiologist). ‘Messenger App’ based communication

>300 cases Thrombolysissince Nov 2014

>500Code Stroke Activation

10 min 30 min

9.7% of all ischemic stroke cases ; 90% of candidate

CASE• Male, 38 yo• Sudden right side weakness, aphasia• Onset 1 hours

Result

•Good recanalization, TICI III

•After 24 hours, the symptom improved (motoric power from 0/5 become 4/5)

•Fully recover after 5 days (no paresis, no aphasia)

•Currently, active as physician

During pandemic era..• Patients with stroke who require hospitalization during pandemic are at increased

risk of suboptimal outcomes.

• Currently, in the setting of COVID-19 pandemic, similar medical emergencies such as cardiopulmonary arrest (code blue) are being modified to the protected designation to provide an additional layer of protection for healthcare professionals and patients.

• These measures include the use of personal protective equipment (PPE) andmodifications to human performance factors in relation to triage processes, team member role designation, and dynamics while caring for patients during a protected code.

Protected Code Stroke

SCREENING• Travel history ≤ 14 days (travel abroad or local transmission)

• Risk of infectious contact

• Infectious symptoms

• Neurological symptoms

• For patients being transferred from other health facilities, an infection control screen and travel history screen should be completed and communicated before transfer.

Protected Code Stroke

Activated

Protected Code Stroke• The appropriate use of PPE by all team members → full-sleeved gown,

surgical mask, eye protection (face shield and/or goggles), head covering and gloves.

• A fitested N95 respirator when there is an aerosolizing procedure →oropharyngeal/nasal (open) suctioning, bag-valve-mask ventilation, and intubation

• Recommend placement of a surgical mask on the nonintubated patient →should remain on the patient during transportation to, during, and back from imaging if the patient is able to tolerate.

• Avoid exam maneuvers that increase repeat contact between provider and patient such as figer-nosefinger and repeat assessments such as for motor and speech.

TAKE HOME MESSAGE• Clinical assessment and intervention during the hyperacute stroke

phase have unique challenges during the COVID-19 pandemic

• There are challenges to maintaining high quality care and promoting the best chance for recovery, while at the same time preventing transmission of pathogens to team members or other patients.

• Vigilant screening processes, proper adherence to established infection prevention and control measures, and a coordinated team response all contribute to a safe and resilient clinical stroke team during these challenging times.

TIME IS STILL BRAIN