1. University at Buffalo Neurosurgery
Defining the Elements and Challenges of Developing a Comprehensive Stroke Center
L. N. Hopkins, M.D.
University at Buffalo Neurosurgery

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
Ownership/Founder
Intellectual Property Rights
Other Financial Benefit1
Toshiba, Medtronic, Microvention
None
Claret, Boston Scientific, Medina, Ostial, Apama, Ocular, Silk Road, TSP
TSP

3. Why invest the in the development of this pathway?
A hospital must be fast and efficient to provide care to patients within delineated timeframes
There is continual downward pressure on these timeframes
The threat of losing accreditation to care for stroke patients looms if the metrics can’t be met consistently
Providing stroke patients with the fastest AND best treatment does make a difference

4. NIH Targets for Stroke Care
Door to MD…………….…...…………10 min
Door to CT…………………………….25 min
Door to CT interpretation…………….45 min
Door to tPA…….……………………...60 min
Access to Neurology…….…….……..15 min Access to Neurosurgery….…….…….2 hrs
Door to admission……....……… hrs

5. Gares Vascular Institute The Construct…
Designed to promote collaboration and “collisions” across disciplines

7. Core Neuro Cath Labs Cardiac Cath Labs IR Cath Labs
Collaboration Area
Control
Neuro Cath Labs
Cardiac Cath Labs
IR Cath Labs
Peripheral Vascular Cath Labs

8. The equipment… State of the art CT and MR imaging Angiography
Hybrid OR suite(s)
Neurosurgical specific OR’s
High quality microscope
Neuro-monitoring
Stereotactic neuro-navigation

9. Evaluation of a Stroke Patient
Pre-hospital evaluation
Outside ER
EMS
Triage in the Gates Vascular Institute (GVI) ER—
Patients met at the door by ER physicians with a specific interest in vascular patients
Immediate evaluation with imaging
Patients receive further treatment in a neuroscience-specific ER pod
Simultaneous evaluation by Stroke Neurology and Endovascular Neurosurgery
Treatment decision rendered and further care delivered as appropriate based on the selected intervention (i.e. tPA and/or neurointervention)

10. Pre-GVI evaluation at ‘Spoke’ Hospitals
Niagara Falls
Memorial
Hospital
Medina Memorial
United Memorial
(Batavia)
Wyoming County
Community Hospital
Jones Memorial
Olean General
Lake Shore
Brooks Memorial
WCA Hospital
Gates Vascular
Institute
Bertrand Chaffee

11. Pre-hospital Pathway
Outlying spoke hospital (or the EMS team if coming directly to the GVI) discusses the case with the vascular ED physician
If appropriate, tPA administered prior to transfer
Pre-hospital notification paged out
ETA
NIH (with main components of the neurologic exam)
Verification of whether or not tPA was administered
Neurology and Neurosurgery are waiting on the patient when they arrive at the door of the GVI ER

12. Real life in the Neuroscience ED…
55 year old man with atrial fibrillation was brought to the GVI ER by EMS ~2 hrs after the acute onset of left sided weakness. NIHSS 9

13. Real life in the Neuroscience ED…
Evaluation in triage by ED physician
Treatment:
tPA
Intervention
Initiation of stroke diagnostics
Stroke page
Neurology
Neuroendo-vascular
Radiology
Basic labs
EKG
CT stroke study
MRI
Pre-Hospital Stroke page

14. Real life in the Neuroscience ED…
Evaluation is completed and treatment is plan is finalized within minutes of arrival
Patient is found to have a right M1 thrombus– administered tPA and taken for thrombectomy
Enrolled in SWIFT PRIME trial evaluating the effectiveness of tPA alone vs. tPA AND mechanical thrombectomy

18. Clot retrieval…restoration of flow

20. After procedure – NIHSS 1
Discharged to home with outpatient PT on POD4

21. But what if it the stroke patient is in our hospital?

22. 62 year old man is who presented to the hospital with unstable angina is undergoing cardiac stent placement.
Near the end of the procedure, he is noted to have facial droop, slurred speech and hemiparesis

23. Neuro-endovascular surgeon is notified and immediately performs cerebral angiogram
Because the various specialties are working in such close proximity, the neuro-endovascular surgeon was immediately available to go to the cardiac cath lab and perform a cerebral angiogram without the need to transport the patient, thus avoiding delay in diagnosis/treatment

24. Comprehensive and efficient care Research
What are the underlying structural elements that lead to continual process improvement?
Comprehensive and efficient care
Research
Clinical
Basic Science
Translational
Accreditation

25. What now… Constant & honest self-evaluation Push for improvement
Pursue perfection

26. “To improve is to change; to be perfect is to change often
“To improve is to change; to be perfect is to change often.” Winston Churchill