Stroke and Neuro-Intensive Care at OHSU Helmi L. Lutsep, MD Oregon Stroke Center Oregon Health & Science University

Approved/Cleared Acute Stroke Treatments IV tPA up to 3 hrs (4.5 hrs per Science Advisory) after symptom onset Merci Retrievers and Penumbra System in large vessel occlusions generally up to 8 hrs after symptom onset Can treat patients that are not IV tPA eligible Can treat patients with residual clot after IV tPA

INR Activation Volume 7-09 to 4-11

Stroke Volume OHSU

Stroke Code Team Transfer center Stroke MD INR MRI Neurosci ICU Stroke coordinator, research assistant Transfer center INR MRI Anesthesia, rapid response Neurosci ICU Neurosurgery

Telemedicine/Telestroke OHSU consultant Obtains patient history, observes exam Views images via teleradiology Discusses management with local provider

Telemedicine: OHSU Stroke Mid-Columbia OHSU Mercy Columbia Memorial Adventist Willamette Valley Salem Hospital 2011 Rogue Valley 2011

Stroke Code Team Transfer center Stroke MD INR MRI Neurosci ICU Stroke coordinator, research assistant Transfer center INR MRI Anesthesia, rapid response Neurosci ICU Neurosurgery

OHSU Acute Stroke Team Stroke Neurologists Clark, W Lutsep, H McDaneld, L Nurses, Coordinators Dolan, M Foley, J Jamison, S Larson, D Seisler, K Research Assistants Feest, K Gard, L Spriggs, K Tilden, N

OHSU Clinical Stroke Trials CREST OHSU 118 VA 6 Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Patient Case: 68 Year-Old Man Patient last known normal at 2:30 AM but awoke at 6:00 AM with left hemiparesis, right gaze preference At outside ED he is outside of tPA window NIHSS=21 Transferred for embolectomy 5 hours after last known normal

Stroke Code Team Transfer center Stroke MD INR MRI Neurosci ICU Stroke coordinator, research assistant INR Transfer center MRI Anesthesia, rapid response Neurosci ICU Neurosurgery

Patient Case: 68 yo Baseline NIHSS=21 DEFUSE 2 Imaged 5 hrs post last known normal

M1 Occlusion Pre and Post Embolectomy Pre Treatment Post mechanical embolectomy with Solitaire device as part of SWIFT trial: Revascularized (TICI 3) at 8 hrs 40 min post last known normal

Patient Case: Post Treatment Imaged 12 hrs Post Last Known Normal

Stroke Code Team Transfer center Stroke MD INR MRI Neurosci ICU Stroke coordinator, research assistant Transfer center INR MRI Anesthesia, rapid response Neurosci ICU Neurosurgery

Patient Case: 68 Year-Old Man Patient observed for edema in neuro ICU , treated for urinary tract infection Discharge NIHSS=4 Day 30 NIHSS=2

17 Beds

Neurocritical Care at OHSU October 2006 Dedicated space = Neuroscience Intensive Care Unit 7NSICU Admission of neurosurgical and neurology patients Team expansion (residents, fellows, PAs) 24/7 in-house coverage

OHSU NSICU Patient Population Neurosurgery (~75%) SAH (aneurysmal, AVM) ICH (IPH + IVH) Tumor surgery Hydrocephalus (+ infect) SDH Spine surgery INR procedures Neurology (~25%) Ischemic stroke, TIA Neuromuscular disease Seizures Encephalitis Meningitis

Multidisciplinary Approach Neurocritical care nurse Respirator therapist Neurointensivist Neurosurgeon Neurologist Interventional neuroradiologist Pharmacist Physiotherapist Occupational therapist Speech therapist Social worker Case manager Consultant(s) (eg. Cardiology, Infectious Disease, Anesthesiology, Radiology, Nephrology, Endocrinology, Palliative Care, etc.) Truly comprehensive care of patients suffering from nervous system disorders and who are critically ill

OHSU Neurocritical Care Service, Patient Volume / Month (n=9546 patient days / last 19 months) continuous overflow into other units 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 2008 2009 (n=5807) 2010

OHSU’s Neurocritical Care Service Provides the only specialized ICU in Oregon for patients suffering from nervous system disorders and who are critically ill Offers unique diagnostic and interventional opportunities for further evaluation and treatment Features dedicated individuals with outstanding expertise and the ultimate ambition for excellence in ICU care