Isolated weakness right index finger JS Kim, Neurology, 2002 Diffusion weighted imaging
“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
Advantages of mechanical thrombolysis Decreased or no need for lytic agent Decreased or no need for lytic agent More rapid and effective clot disruption More rapid and effective clot disruption
Concentric Retriever device
FDA approval August 2004
Carotid angioplasty and stenting: an evolving technology
FDA HDE for PFO closure devices
How do we apply these advances in New Hampshire? We have many small hospitals separated by miles, mountains and misgivings? We have many small hospitals separated by miles, mountains and misgivings? Limited interest or resources in stroke Limited interest or resources in stroke
Stroke Medical DRGs 9/99-10/01
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): 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): 3
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
NH stroke task force Timothy Lukovits, MDDartmouth Hitchcock Medical Center Donna Clark, MDDartmouth Hitchcock Medical Center Jonathan Friedman, M.D.Dartmouth Hitchcock Medical Center Robert Zwolak, M.D.Dartmouth Hitchcock Medical Center Parker Towle, M.D.Dartmouth Hitchcock Medical Center Sarah Johansen, MDDartmouth Hitchcock Medical Center Wendi Guillette, OTR/LHealthsouth Rehabilitation Hospital Elva Hawkins, RNElliot Hospital David Hogarty, MDHealthsouth Rehabilitation Hospital Patricia Locuratolo, MDNeurologist - Portsmouth Douglas Black, MDNeurologist - Portsmouth Archie McGowan, MDPortsmouth Radiological Associates, PA Rachel RoweFoundation for Healthy Communities Sue PrentissNH EMS Powen HsuNew Era Medicine Craig DayAHA/ ECC Manager – ME, NH, VT Nancy PederziniAHA/ Advocacy Director – NH
Stroke Educ. activities in NH/VT Concord Neurology for Primary CareNovember 19, 2003 Concord (NH Brain Injury Assoc. Meeting) November 19, 2003 DHMC Rehab ConferenceMarch 2, 2004 DHMC Rehab Conference March 9, 2004 New LondonMay 3, 2004 Berlin (AVH)May 18, 2004 Nashua (Southern NH Medical Center)June 24, 2004 Concord Neurology for Primary Care November 10, 2004 NH Medical SocietyNovember 10, 2004 Huggins Hospital (NH Emergency Medicine)November 18, 2004 DHMC Cardiology ConferenceDecember 6, 2004 Woodsville (Cottage)December 21, 2004 Elliot HospitalJanuary 20, 2005 Norwich, VT EMTs January 5, 2004 Woodstock, VT Primary Care Neurology ConferenceFebruary 25, 2004 Stowe, VT Northern New England Neurology ConferenceFebruary 26, 2004 Bennington, VT (Southwestern VT Medical Center) September 11, 2004
Other Task Force Activities Meeting in Portsmouth, NH January 2005 Meeting in Portsmouth, NH January 2005 Encourage use of GWTG-Stroke and Primary Stroke Center concept Encourage use of GWTG-Stroke and Primary Stroke Center concept
Why should we consider organizing stroke care regionally? Networking will improve use of limited resources We can share continuing education activities We can share continuing education activities We can share limited diagnostic and therapeutic resources (e.g., subspecialty cerebrovascular disease care for complicated cases) We can share limited diagnostic and therapeutic resources (e.g., subspecialty cerebrovascular disease care for complicated cases) Imagine a new revolutionary treatment becomes available Imagine a new revolutionary treatment becomes available Improved patient access to clinical studies We can learn from and be stimulated by each others’ experiences and enthusiasm
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.
Small filling defect (?embolus) in the mid to distal left pericallosal artery.
3 x 3 cm pulmonary AVM in the left lower lobe.
C onfused V ascular A nalyses We need to prevent CVAs!