1. Implementing pathway for Neuro-intervention 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 1

2. 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….

3. 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.

4. UHNS Acute Stroke Unit (ASU) 2001 to 2010 Outcome/Results
Integrated working 32 Beds
24 Beds
39 Beds

5. Where are we?
Location
In relation to neighbours, borders and other Network areas. Type of population and size 5

7. Regional Thrombolysis rota for 24/ 7 cover across the region ( Feb 2011)

8. Telemedicine ( April 2012)

9. Until 2010 No clear Neuro- interventional pathway

10. First encounter…….. 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

11. Cervical Halo

12. Basilar occlusion on CTA
Discussion with Orthopaedic Surgeon/ Neuro- radiologist
Agreed for Intravenous and intra-arterial
Anaesthetist arranged
Whole episode was chaotic
Since no clear pathway - theatre team difficult to co- ordinate
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

13. Time is Brain……

14. Pathway for ischaemic stroke treated with r t-PA?
999
Triaged in A and E
Within Hrs

15. Neuro-interventional pathway
999
Time is Brain

16. The Team Interventional Neurorradiologist 1 Radigrapher 1 Nurse
Stroke Physician
Anaesthetist / ODA

17. Agreed patient group… Age<75 Previously fit and well
Working hours (out of hours if interventional neuroradiologist available)

18. Teams that we engaged Radiology / Neuroradiology Anaesthetics/ ITU
Neurosurgery
Emergency Medicine

19. 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.

20. 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

21. To get a Standard Operation Pathway agreed for Stroke as E 1
Emergency theatres prioritisation codes
E1 Immediate transfer to theatre
E2 Within 6 hours
E3 Within 12 hours
E4 Urgent, but timing not critical

22. 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
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

23. Key paperworks…… Consent Sheets form 1 / form 4
Patient information sheet
Theatre check list
IA log
Nursing pathway for Intervention

24. Time CT angio
IV alteplase given
Y / N
Time of IV alteplase bolus
Consent/assent signed
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
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

25. Suitable patient 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)

26. 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.

27. 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

28. Prepare the patient (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

29. Prepare for intervention
Start the intra-arterial intervention log
Theatre team to move patient onto the intervention table
Theatre team to cover patient with sterile sheets
Anaesthetist and ODA to commence local/ general anaesthesia
Neuroradiologist or scrub nurse to clean/ disinfect groin.

30. During / After Intervention
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.

31. 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

32. Barriers…..
Trust
Commissioning
Costing
Getting all the teams together

33. Media – Not a good idea Pioneering stroke drugs saved Patient
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. ​

34. Costings…… 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

35. Cost for Post Stroke Care
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
Social / Residential care:
mRS 5 : £550 / week ( £ 28,600/ year)
mRS 4: £ £ 450 /week ( £ 20,800 - £ 23,400/year)
mRs 3: ( if care required) : £ 300/week ( £ 15,600/year)

36. Funding Primary Care Trust 2 NHS 2 Stroke Network 1 Stroke Fund 1
Intervention Fund 1
Neuroscience Department 1
Geriatric Medicine 1
Under discussion 1

37. HRG Coding
Percutaneous trans-luminal embolectomy / thrombectomy of artery:
L 712
HRG - QZ15 A - Major complication with co- morbidities £ 9554
HRG – Q Z15B – Minor complications £ 5098
HRG – QZ15 C – No complications £3731
On top for Alteplase: you get another 800£

38. Challenges 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

39. Centres in the UK
> 1 per month
5 – 10 / 10 months

40. Frequency of endovascular treatments for acute ischaemic stroke in active centres in 2010
Number of centres 4
1-4
(1 every 3 mo or less) 8
5-9
(one every other month) 5
>=10 6

41. 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

42. Type of Approach
Thrombolysis pathway
Neuro-interventional pathway

43. In Summary Newer interventions needs newer pathway
Part of expansion of Neurosciences Units
Part of the Clinical Research activity
One needs to start somewhere………………..

44. Resources http://www.stroke-in-stoke.info/ You can look at our:
Pathway
Patient Information leaflet
Procedure log
Nurse pathway
Protocols
Data entry file – We are happy to support data

45. Acknowledgements…. Prof Christine Roffe Dr. Sanjeev Nayak
All the Neuro-interventional team / Anaesthetic team/ ITU team / Stroke team/ Exec Board