1. What Happens When your patient is transferred .
Sanjeeva Reddy Onteddu
Vascular Neurology,
Assistant Professor,
Director Stroke program, UAMS.
Medical director ARSAVES.

2. Disclosures
None

3. Objectives Decision on transfers Types and modes of transfers
Care expected at receiving sites

4. Transfer of Stroke patients
Who will need transfers.
Higher Level of Care
No Required specialty

5. Ways for Transfer IDHI-Telestroke Call center (arsaves Call center)
UAMS PCC

6. PCC
Call center
Bridge to OSH physicians
Facilitates Transfers

7. UAMS Stroke Center

8. THEN

9. Transfers for Thrombectomy
High Acuity Patients.
Needs to be transferred on Emergent basis
Flying when safe and faster is encouraged.
When coming to UAMS its called Ischemic Stroke Pathway.

10. Ischemic Stroke Pathway
Will have Continuous updates,
Still use pagers.
Several Stroke team members are notified.
Stroke Faculty, Resident, APRN, Neuro Interventional radiologist,
Anesthesiologist, ED Charge nurse, CT Techs.

11. After Arrival Go Directly to CT scanner
Stroke Faculty/Resident/APRN meets the patient.
Get CT head, CTA head and Neck, CT perfusion.
Neuro IR and Anesthesia team are at CT Room.

12. Decision
Review Data
Decision for go/No go based on CTA and CTP results.

13. Yes Thrombectomy Taken to Thrombectomy
Record Door to puncture, D to Recanalization times
TICI scores Etc..

14. No thrombectomy
Go to ICU if had IV tPA, large stroke or complex patient.
Rarely go to Stroke floor.

15. Thrombectomy DAWN and DEFUSE extended time window to 24hrs.
Stroke Pathway Process.
Number of thrombectomies
Transfers for thrombectomies
cases
cases
cases
cases
as of end of July

16. Patients Transferred to UAMS for Thrombectomies
Reason for No Intervention
 N(132)
% total
Intervention Done 46 35
LG Core Infarct 24 18
Hemorraghic Conversion 2 1
Stroke w/No LVO or Distal Clots 42 32
No Stroke/No LVO on Follow Up Imaging 14

17. Mode of Arrival
Ground Transport
Air transport.

18. DIDO/DOHDI Study looked at PSC to CSC for Thrombectomy
85 (68-111) for PSC DIDO
26 (17-32) for interfacility transport
Stroke.2018 Dec;49(12): doi: /STROKEAHA

19. Our Numbers No clear DIDO numbers tPA to Hub CTA times
200 minutes average.

20. Acute care of Non Thrombectomy Patients
Cerebral edema
Unstable carotids
Low NIHSS for Thrombectomy

21. Large Stroke patients
Cerebral edema
Decompressive Hemicraniectomy

22. Unstable Carotid Plaques
High rates of clot propagation
Close Neuro ICU monitoring
Rarely for Close ICU monitoring for potential thrombectomy patients.

23. Stroke Etiologies Atherosclerotic. Lacunar stroke. Cardio embolic
Other known causes: Dissections, hypercoagulability ..etc
Cryptogenic strokes.

24. Stroke Etiologies- Cardio embolic
Atrial fibrillation and congestive heart disease
Cardio embolic stroke is the most frequent ischemic stroke subtype in very old patients.
Framingham study: A fib causing stroke by age
1.5% for individuals aged years to
23.5% for people aged years.

25. Carotid Atherosclerosis
CTA head and neck
MRA head and neck
C duplex rarely

26. Lacunar Stroke
Imaging
History

27. Secondary Ischemic Stroke prevention
Which Risk factor you Treat
Smoking
Blood pressure
Diabetes
Cholesterol
Reality: xx

28. Blood Pressure Single most important treatable risk factor for stroke
Hypertension in the Very Elderly Trial (HYVET)
The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) trial
the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial
Different Goals for each study
Goals should be <140/90 mmHg
Older than 80 years if diastolic pressure are low then goal should be <150.
Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study.

29. Antiplatelet agents
ASA
Plavix
Aggrenox
Combination ASA and Plavix?

30. Anticoagulation Under Used
44 % of patients with AF aged 65 to 74 years
11 % of patients over 75 years were treated with Warfarin
Sudlow CM, Rodgers H, Kenny RA, Thomson RG. Service provision and use of anticoagulants in atrial fibrillation. BMJ : British Medical Journal. 1995;311(7004):

31. Anticoagulation Warfarin
Dabigatran, Apixiban, Rivaroxaban, Edoxaban appear to be safer and effective in elderly.
Reducing the risk of bleeding
If Warfarin is used monitor INR closely
BP control
If Worried about falls, Interventions to reduce falls

32. Afib + Falls ? AC
Need to fall 295 times a year for fall-related subdural hemorrhages to outweigh benefits of stroke prevention.
Shared Decision Making
Choosing Antithrombotic Therapy for Elderly Patients With Atrial Fibrillation Who Are at Risk for Falls, Arch Intern Med. 1999;159(7): doi: /archinte

33. Stroke Rehab Rehab potential Evaluation
Limited by Co morbid conditions and complications of stroke including dysphagia.
Intensive rehabilitation: three hours per day of therapy.
Less intensive rehab: in SNF, NH.

34. Stroke Net UAMS part of Stroke net
Network of 25 regional centers across the U.S with more than 200 hospitals.
Easy access to Research Studies.
Approved for 3 Stroke Studies since June 2019.

35. Current Clinical Trials
PISCES III
ARCADIA
ASPIRE
SATURN Trial