1. Victorian Stroke Telemedicine A Regional Perspective
Janet May
Victorian Stroke Telemedicine Site Coordinator Latrobe Regional Hospital
25th November 2016

2. Overview LRH background Stroke Telemedicine Pathway
Case study with tissue Plasminogen Activator (tPA) and Endovascular Clot Retrieval (ECR)
Key factors for success/sustainability in a regional setting

3. Importance of Time
1.9 million neurons, 14 billion synapses and 12 kms myelinated fibres are lost each minute during an untreated Stroke*- equates to brain aging 3.6 years each hour
Impact delayed tx has on pt is huge at the other end of their Stroke journey.
Time and cost in hospital and rehab, but more importantly effect of pt’s outcome and quality of life.
Treat Strokes like a STEMI.
*Source: Jeffery Saver; ‘Time is Brain – Quantified’, 2014

4. LRH Emergency Department (ED)
ED annual presentations approximately 30,000
Stroke/TIA admitted inpatients = 227 in 2015
Stroke Telemedicine commenced in Nov ’15
112 VST calls (YTD)
61 Ischaemic Strokes, 10 TIA, 4 ICH, 7 Migraines, 30-other
27 pt’s thrombolysed, 7 transferred for ECR
15 pt’s thrombolysed July 2014 – June 2015
Increase of 80% of patient’s thrombolysed since comm VST
Aim of the program to Improve access to reperfusion therapies and reduce delays in diagnosis and treatment is working

5. How the VST program works…
Phone 1300 TELEMED
( )
Regional Hospital
Stroke symptom onset < 4.5 hours
Paramedics notify hospital
Rapid triage and assessment
CT brain and CTA
Acute stroke therapies
– tPA/ECR delivered within acceptable timeframe
Video consultation with family and regional clinician
Rapid review of brain imaging remotely
Assessment by VST stroke specialist
Acknowledge the principles to Stroke Mg is much more than during hyper-acute stage.
Initial time frame impacts on care that other health professionals deliver in Stroke Unit and Rehab.

6. Case Study Mr N, 78 year old man. Independent, home with wife, MRS=0
PHx of IHD (stable), smoker 30 years ago
Witnessed onset aphasia + right hemiparesis while working in his shed
Stroke onset 12:30pm
NOTE:
Remember stroke onset is last time seen well
Stroke discovery can be different to stroke onset
Modified Rankin Score – scale from 0-6 measures degree of disability or dependence in their daily activities. 0-2 independent, 3-6 – dependent to death.
Be aware of ‘Wake Up Strokes’ – have to take the onset time from last time seen well. If unknown – can’t thrombolyse.

7. VST Pathway AV pre-notification. Pre-order CT scan
Taken directly to CT from AV trolley-18G IVC
Med Reg -R/V pt and attends CT
Med Reg Initiates VST call when baseline diagnosis is established, exclude ICH. +/- CTA
Neurologist R/V’s CT images, timely diagnosis and management
Pt returns to ED for further Assessment + urgent pathology
Neurologist dials into Teledoc for audio-visual consult. NIHSS 23 (severe stroke)
In conjunction with CT results, patient’s pre-MRS, NIHSS score – Neurologist provides Med Reg with management suggestion
Timing of call to VST varies at each site. Some call prior to pt’s arrival.
LRH – call after we exclude ICH.

8. National Institute of Health Stroke Scale (NIHSS)
Internationally recognized tool to determine severity of stroke
Consists of 11 items, scores a specific ability, ranges 0-4
Score
Stroke severity
No stroke symptoms
1-4
Minor stroke
5-15
Moderate stroke
16-20
Moderate to severe stroke
21-42
Severe stroke

9. Background of Thrombolysis
In 2007 the stroke care strategy for Victoria supported the use of thrombolysis for appropriately identified patients, who met the criteria
Radically changed approach to acute stroke management
LRH introduced the use of tPA (thrombolysis) in June 2010
2015 large clinical trials demonstrated clot retrieval intervention almost double benefits in pt outcome than thrombolysis for large artery obstruction
Stroke can be Ischaemic or from haemorrhage.
Thrombolysis is used for ischaemic strokes only – been around now for nearly a decade

10. tPA
The aim of thrombolysis is to recruit as much of the penumbra as we can by breaking down the clot.

11. What is tPA Most effective, evidence-based acute stroke
therapy is thrombolysis with recombinant tissue
Plasminogen Activator (tPA)
Converts plasminogen to plasmin, the major enzyme responsible for clot breakdown
Thrombolysis can only be used for ischaemic strokes
Alteplase is the drug used in thrombolysing strokes who meet the criteria
Other thrombolytic drug trials (e.g Streptokinase) halted due to high rates of ICH

12. Giving Alteplase
Point of care INR check for pt’s on warfarin/New Oral Anticoagulants (NOACs)
Meet eligibility criteria
>18 years - not absolute
Expensive
0.9mg/kg, max. dose 90mg. Don’t shake.
Administration: 10% as bolus (IV push over 1 min), remaining 90% as infusion over 1 hr.
Short half-life - 5 minutes
NIHSS score 2 hrs, 24 hrs post Alteplase and day 7/discharge
Avoid IVC, art line insertion, NGT for 24hrs, CCU for 24hrs
Post tPA obs in protocols –talk for another day
Thus > 50% of t-PA is cleared from plasma within 5 minutes after discontinuance of an IV infusion and approximately 80% is cleared within 10 minutes.
Older clots have more fibrin cross-linking and are more compacted or in plain English older clots are more difficult to dissolve.
Beyond that time, the efficacy diminishes and higher doses are generally required to achieve desired lysis and the great the risk of unwanted complications.
Reteplase is less fibrin selective and has longer half life
IF BP >180/110 should be treated prior to commencing t-PA
7% of pts with ischaemic Stroke receive t-PA
Mortality rate =21% not tx t-PA, 17% for pts tx with t-PA –Stroke Foundation
Time frame: Studies done <6 hrs of symptoms. Mortality rate wasn’t increased

13. Cautions Signs of angioedema, anaphylaxis, bleeding
ICH – 6.4% of pts receiving Alteplase – 50% occurs in first 24hrs and half are fatal
Minor bleeding is common – look at gums, IVC site
Poorer outcomes:
Severe impairment (NIHSS >22)
>85 years age
Hypertensive
Hyperglycaemia

14. Aim - 60mins Door to Needle time
Pre-VST
VST LIVE
Pre-VST DNT = 90 minutes
Pre-VST CT time = 17 minutes
Reasons for delays pre-VST
Different process
CT not initial priority
Time for CT interpretation
Due to multiple delays in time pt’s could exceed 4.5hour time frame and >6hours for ECR
VST DNT = best 40 minutes
VST CT time = best 1 minute
Mr N’s Door to CT time = 12mins
Mr N’s DNT = 40mins
Door to ED exit time = 1hour 15mins (transfer RMH for ECR)

15. ECR
Decision to pursue ECR –large vessel occlusion-best patient outcome
VST Stroke Physician contacts receiving ECR Physician (RMH) – determine suitability for ECR.
Urgent interhospital transfer – 000 – request <15 minute response. AV Code 1
Adult Retrieval Victoria only required for patients with airway compromise, coma or haemodynamically instability
Angioedema kit to go with patient
Can be transferred with tPA infusion insitu
ECR – highly effective tx reduces disability and death after ischaemic stroke du to lg vessel artery occlusion
Requires specialist skills – avail RMH, soon to be avail at MMC
Majority are transported by ALS crew on Code 1

16. Mr N’s Outcome Endovascular clot retrieval <6hours
ECR procedure took 30mins
Patient was responding yes/no & moving R)side post ECR & improved daily
Returned LRH Rehab 7 days post ECR
D/C home one month later
Post mRS (on discharge) = 2
Slight speech delay & slight R)sided deficit. Independent with ADLs
(Remembering that he had aphasia + right hemiparesis and NIHSS of 24)

17. Key Factors to Success
Mr N’s wife remembered the FAST acronym and dialled 000 immediately
AV pre-notified LRH AUM
Immediate CT, CTA and CTP
Called VST as early as possible
Neurologist received images within 2minutes
Rapid CT interpretation & diagnosis
Med Reg was proficient with NIHSS
Administration of timely tPA (aiming for DNT 30-40minutes. KPI<60 mins)
Patient considered for ECR <6hours
Teamwork!

18. Challenges Differentiating TIA/other diagnosis
Wake up Strokes – determining time
Stroke mimics – migraines, functional, seizures, syncope, hypoglycaemia, sepsis, etc
Consult with VST/Neurologist ASAP

19. Key Factors to Success- Telemedicine
Close collaboration with the Florey
Active input from supportive executive and influential key stakeholders
Close working relationships with local ambulance crew  consistent pre notification
Ongoing education to rotating medical staff
Everyone involved can contribute to timely outcome:
- Paramedics, Clerks, Orderlies, Drs, Nurses,
Radiographers
Shaving minutes off delays - saves millions of neurons
Save a Minute, Save a Day

20. Acknowledgements
The Florey Institute. Particular thankyou to Prof Chris Bladin, Dominique Cadilhac, Michelle Vu, Dr Katie Bagot
VST Site Coordinator colleagues, particular Lauren Arthurson Site Coordinator Echuca Regional Health and Emma Marino (predecessor at LRH)
Nerylee Morris- Stroke Coordinator, LRH
Carolyn Beltrame- CNS ED LRH
Inform Me, 2016:
Stroke Foundation, 2016:

21. Questions