1. The Future of Stroke James D. Fleck, M.D. Medical Director IU Health Methodist Hospital Comprehensive Stroke Center

2. Disclosures None

3. Stroke Statistics Heart Disease and Stroke Statistics 2014 ~795,000 new or recurrent strokes/year 87% Ischemic, 10% ICH, 3% SAH 1 stroke every 40 seconds in US 1 death from stroke every 4 minutes in US 4 Th leading cause of death in US Decline in stroke mortality

4. US age-standardized death rates* attributable to CVD, 2000 to 2010. Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

5. Prevalence of stroke by age and sex (National Health and Nutrition Examination Survey: 2007–2010). Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

6. Annual rate of first cerebral infarction by age, sex, and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1999). Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

7. Annual age-adjusted incidence of first-ever stroke by race. Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

8. The 22 leading diagnoses for direct health expenditures, United States, 2010 (in billions of dollars). Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

9. Projected total costs of cardiovascular disease (CVD), 2015 to 2030 (2012 $ in billions) in the United States. Alan S. Go et al. Circulation. 2014;129:e28-e292 Copyright © American Heart Association, Inc. All rights reserved.

10. Treatment of Acute Ischemic Stroke NeuroprotectionReperfusion

11. Time Is Brain !! Neurons Lost Synapses Lost Accelerated Aging Per Stroke 1.2 billion 8.3 trillion 36 yrs Per Minute 1.9 million 14 billion 3.1 wks Per Hour 120 million 830 billion 3.6 yrs

12. Modified Rankin Score 0 = No symptoms at all 1 = No significant disability despite symptoms: able to carry out all usual duties and activities 2 = Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance 3 = Moderate disability: requiring some help, but able to walk without assistance 4 = Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance 5 = Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 6 = Patient death

13. Endovascular Ischemic Stroke Treatment MR CLEAN - NEJM 2015; 372: 11-20 –Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in Netherlands ESCAPE – NEJM 2015; 372: 1019-30 –Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis minimizing ct to recanalization times EXTEND- IA – NEJM 2015; 372: 1009-18 –EXtending the time for Thrombolysis in Emergency Neurologic Deficits SWIFT – PRIME –Solitaire FR With the Intention For Thrombectomy as PRIMary Endovascular treatment for acute ischemic stroke

14. Endovascular Ischemic Stroke Treatment MR CLEAN – Netherlands –Age > 18 yrs ESCAPE – Canada / US / others –Age > 18 yrs EXTEND IA – Australia / New Zealand –Age > 18 yrs SWIFT PRIME – US / Europe –Age 18-80 yrs

15. Endovascular Ischemic Stroke Treatment # PatientsMean Age OcclusionTime Window NIHSS MR CLEANIA – 233 Control 267 65yDistal ICA or MCA or ACA IA < 6 hr< 2 Mean: IA 17 Control 18 ESCAPEIA – 165 Control150 70-71yDistal ICA or MCA 12 hr from onset (15.5% > 6 hr) None at entry Mean: IA 16 Control 17 EXTEND IAIV – 35 IV/IA - 35 IV- 70 y IV/IA – 69y ICA or MCA (1 st or 2 nd segment) IV < 4.5 hr IA start < 6 hr finish < 8 hr None at entry Mean: IV 13 IV/IA 17 SWIFT PRIME IV – 98 IV/IA - 98 IV – 66y IV/IA – 65y Distal ICA or prox MCA IA < 6 hr groin puncture 8-29 Mean: IV 17 IV/IA 17

16. Endovascular Ischemic Stroke Treatment Radiology Inclusion ASPECTS% patients receiving iv tpa Median time stroke onset to iv tpa MR CLEANCTA/MRA Shows occlusion No inclusion # Median 9 IA 87.1% Control 90.6% 85-87 min ESCAPENCCT ASPECTS 6-10 CTA Mod-good collaterals Median 9IA 72.7% Control 78.7% IA 110 min Control 125 min EXTEND IANCCT CTA CTP 100 %IV 145 min IV/IA 127 min SWIFT PRIME CTA/MRA Shows occlusion < 6 was exclusion 100%IV 117 min IV/IA 110 min

17. CT Angiography and Perfusion

18. CT Perfusion

19. ASPECTS

20. Endovascular Ischemic Stroke Treatment IA treatmentretrievable stent IA with GA Median stroke onset to groin Median stroke onset to reperfusion MR CLEAN Any type mechanical thrombectomy (Rare thrombolytic agent) 81.5%37.8%260 min ESCAPE Retrievable stent recommended (not mandated) 86.1%9.1%185 min218 min EXTEND IA Solitaire100%36%210 min253 min SWIFT PRIME Solitaire100%Stroke onset to first deployment 252 min

21. Endovascular Ischemic Stroke Treatment 90 day MRS 0-2TICI 2b/3 MR CLEANIA – 32.6% Control – 19.% OR 2.16 (1.39-3.38) “Absence residual occlusion” IA – 75.4% Control – 38.9% ESCAPEIA – 53% Control – 29.3% OR 1.7 (1.3-2.2) IA – 72.4% EXTEND IAIV -40% IV/IA – 71% P = 0.01 IA -86% SWIFT PRIME IV – 35.5% IV/IA – 60.2% OR 2.75(1.5-4.95) IA – 88%

22. Endovascular Ischemic Stroke Treatment Symptomatic ICH Mortality MR CLEANIA – 7.7% Control – 6.4% 30 day IA – 18.9% Control – 18.4% ESCAPEIA – 3.6% Control- 2.7% IA – 10.4 % Control- 19% EXTEND IAIV- 6% IV/IA – 0% IV – 20% IV/IA – 9% SWIFT PRIME IV- 3.1% IV/IA – 1.0% IV – 12.4% IV/IA – 9.2%

23. Endovascular Ischemic Stroke Treatment Do you have Interventional MDs and teams? –At your hospital? –At another hospital? –Available 24/7/365? –How do you access Interventional teams? What advanced imaging is available? Which patients receive advanced imaging? When do patients receive advanced imaging?

24. Mobile Stroke Units Berlin, Germany Univ Texas-Houston Medical School – Houston, TX Cleveland Clinic

25. Mobile Stroke Units

27. PHANTOM –S –Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study –Berlin Germany –STEMO – Stroke Emergency Mobile –JAMA 2014; 311: 1622-1631

28. PHANTOM-S Mean alarm-to-treatment time –51.8 min –76.3 min control/usual time –No increased risk for intracerebral hemorrhage or death

29. Mobile Stroke Units Ambulance with CT scanner Ambulance personnel EMS organization Point-of-care labs Telemedicine connection Cost

30. Future of Stroke Care Organization –PSC and CSC –State laws requiring where patients receive care Neuroprotection –EMS deployment of meds Enhancing recovery and rehabilitation

31. Questions?