A publication of Penn State Hershey Stroke Center, a division of Penn State Hershey Neuroscience Institute
PENUMBRA
quarterly
summer 2014
Inside this issue:
PSC vs. CSC Cover
Case of the Quarter 2
LionNet Update
3
Research Corner 4
Event Calendar 4
Penn State Hershey
Stroke Center
717-531-STRK (7875)
Kevin M. Cockroft, M.D., M.Sc.
Co-Director
717-531-1279
Raymond K. Reichwein, M.D.
Co-Director
717-531-1803
Kathy J. Morrison, M.S.N. R.N.
Program Manager
kmorrison1@hmc.psu.edu
717-531-1104
Jennifer Humbert, M.S.N., R.N.
LionNet Telestroke Manager
jhumbert2@hmc.psu.edu
717-531-1276
Alicia Richardson, RN, CNS
Stroke Program Coordinator
arichardson2@hmc.psu.edu
717-531-1390
Primary Stroke Center vs.
Comprehensive Stroke Center
What’s the Difference?
Primary Stroke Center (PSC) designation
was initiated in 2004 by The Joint
Commission, and indicates that a hospital
has demonstrated the capability to rapidly
evaluate acute stroke patients, provide IV
tPA according to guidelines, and provide
evidence-based acute care, therapy,
education, and discharge planning. PSC
staff and providers who care for stroke
patients are educated and competent.
Complex stroke patients, and those
requiring advanced intervention, are
transferred to Comprehensive Stroke
Centers.
Comprehensive Stroke Center (CSC)
designation was initiated in 2012 by
The Joint Commission, and indicates
that a hospital has met the criteria for
PSC, as well as demonstrates the following
capabilities: advanced neuro-imaging,
endovascular neuro-intervention
according to guidelines, a sufficient
volume of complex stroke patients,
education and competency requirements
for staff and providers, follow-up of
patients after discharge, and a database
for tracking complications and patient
outcomes.
The side-by-side comparison illustrates the
differences between these two certifications.
Primary Stroke Centers
Comprehensive Stroke Centers
Patient Care
Stabilize and treat most cases
of acute ischemic stroke.
Cares for all types of stroke patients, both ischemic and hemorrhagic and including complex
cases requiring advanced technology, specialized
diagnosis and higher levels of treatment.
Advanced Imaging
No advanced imaging (such as CT angiography,
CT perfusion or transcranial doppler) required.
24/7 access to advanced imaging including
CT angiography, CT perfusion, or transcranial
doppler required.
Endovascular Intervention
Not required.
24/7 access to endovascular interventions
such as mechanical thrombectomy for acute
ischemic stroke, aneurysm coiling, and arteriovenous malformation embolization.
Neurocritical Care
No requirement for a separate neuroscience
ICU.
Dedicated neuroscience intensive care unit
staffed 24/7 with neurocritical care experts.
Neurosurgery
Access to neurosurgery within 2 hours.
On-site neurosurgical providers available
24/7 to perform complex neurovascular
procedures, such as aneurysm clipping, AVM
resection, and carotid endarterectomy.
Patient Transfers
Sends complex patients and those who
require advanced intervention to CSC.
Receives patients from Primary Stroke Centers
following stabilization.
central pa region stroke centers
Pinnacle Health System
WellSpan Health
Memorial Hospital
Lancaster General
Hanover Hospital
Chambersburg Hospital
Waynesboro Hospital
Ephrata Community
Hospital
Penn State Milton S. Hershey
Medical Center
penumbra quarterly
case of the quarter
Pipeline Embolic Device Provides
Revolutionary Treatment for Brain Aneurysms
More recently, the technique of flow-diversion has become popular
as an alternative to coil embolization for these challenging aneurysms.
In a flow-diversion procedure, a mesh-like tube (similar to a stent)
is placed across the neck or base of the aneurysm. The device
literally diverts flow away from the aneurysm, causing it to thrombose
(occlude) over time. Complete thrombosis may take weeks or
months, depending on the size of the aneurysm and the degree of
flow diversion achieved, but once the aneurysm is occluded, it will
not reoccur. Because this treatment does not result in immediate
aneurysm occlusion, it is not recommended for patients with
subarachnoid hemorrhage (stroke) from a recently ruptured aneurysm.
In the United States, the Pipeline Embolic Device (Covidien
Neurovascular, Irvine, CA) is the only device approved by the FDA
for the flow-diversion treatment of brain aneurysms (Figure 3).
This 73-year-old male presented with double vision. He was a long-term
smoker with a history of hypertension, peripheral vascular disease,
and an abdominal aortic aneurysm. His examination revealed a mild
left VIth nerve palsy, but no other neurological deficits. The patient
was referred for a brain MRI, which revealed a large mass within the
left cavernous sinus (Figure 1). The signal characteristics on MRI
were consistent with a vascular lesion, most likely an aneurysm.
Figure 1: Axial T2-weighted MR image
shows a large flow void consistent with an
aneurysm in the region of the left cavernous
sinus (arrow).
The patient was referred for
neurosurgical consultation and
underwent a diagnostic cerebral
angiogram to better assess the
area of the suspected abnormality. The angiogram (Figure 2)
demonstrated a large saccular
aneurysm arising from the
intracavernous left internal carotid artery. Given the patient’s symptoms and the size of the aneurysm, treatment was recommended to
occlude the aneurysm.
Figure 3: Photograph of the Pipeline Embolic Device (PED). The device is delivered
through a flexible microcatheter and consists of a self-expanding mesh cylinder composed of
forty-eight braided strands of cobalt, chromium and platinum.
Figure 2: AP (A) and lateral (B) views from a left internal carotid artery (ICA)
angiogram demonstrating a large saccular aneurysm arising from the intracavernous ICA
(arrows).
Based on the size, location and configuration of this patient’s
aneurysm, treatment with a Pipeline Embolic Device was
recommended. The patient was pre-treated with aspirin and
clopidogrel (PLAVIX) for one week to prevent thrombus formation
on the device itself. He was then taken to Penn State Hershey’s
neuroendovascular suite and a single Pipeline Embolic Device was
placed across the base of the aneurysm (Figure 4). The patient
tolerated the procedure well and he was discharged to his home
the next day.
Many years ago, surgery for this type of aneurysm would have
required a risky and potentially disfiguring operation through the
cavernous sinus, or the permanent occlusion of the carotid artery
itself. With the advent of endovascular techniques, it became possible
to occlude aneurysms of this type with endovascular coils and preserve
the parent vessel. However, large aneurysms were and still often are,
difficult to completely and permanently occlude with coils alone.
Aneurysm recurrence is more common and the number of coils
required often makes treatment expensive and time consuming.
2
717-531-STRK (7875 )
LionNet Update
We welcome our newest LionNet telestroke partners: Evangelical
Hospital, Lancaster Regional Medical Center, and Heart of
Lancaster Medical Center have all become active partners since
January 2014, giving the network a total of ten partners. Penn
State Hershey has completed more than 900 consults since July
2012, and maintains an impressive network treatment rate of
more than 25 percent, and transfer rate of less than 30 percent.
Figure 4: Lateral skull X-ray taken during
treatment showing the newly placed Pipeline
Embolic Device (arrow) within the left internal
carotid artery.
The patient continued on dual
antiplatelet therapy for three months.
A follow-up angiogram at that
time revealed complete occlusion
of the aneurysm (Figure 5),
and his antiplatelet therapy was
discontinued. His left VIth nerve
palsy and double vision gradually
resolved after treatment.
a
If you are interested in becoming a LionNet partner or would
like to hear more about the program, please contact Jen
Humbert, RN, LionNet project manager, at 717-531-1276.
B
For stroke patient transfers to Penn State Hershey Medical
Center, please contact Patient Logistics at 717-531-8856. For
outpatient referrals to Penn State Hershey Neurology or Penn
State Hershey Neurosurgery, please call 717-531-3828.
Current LionNet Partners
Carlisle Regional Medical Center
Ephrata Community Hospital
Evangelical Community Hospital
C
Hanover Hospital
Figure 5: Comparison lateral views from
the patient’s cerebral angiograms. Photo 5A
shows the pretreatment appearance of the
aneurysm and internal carotid artery. Photo 5B
illustrates stasis within the aneurysm (arrow)
after initial Pipeline Embolic Device placement.
Photo 5C (from the patient’s follow-up angiogram
performed three months after treatment) shows
complete occlusion of the aneurysm with
restoration of a normal appearance to the
internal carotid artery.
Heart of Lancaster Regional Medical Center
Lancaster Regional Medical Center
Memorial Hospital
Mount Nittany Medical Center
St. Joseph Medical Center
The Good Samaritan Hospital (Lebanon)
3
penumbra quarterly
Research Corner
Trial Name Sponsor Purpose POINT Platelet Oriented
Inhibition in New TIA
and minor ischemic
stroke University of
Southern
California
supported by
NIH To determine if
clopidogrel is effective
in preventing major
ischemic vascular events
at 90 days SHINE Stroke Hyperglycemia
Insulin Network Effort University of
Virginia
supported by
NINDS & NIH To determine the
efficacy of tight glucose
control with IV insulin
infusion in
hyperglycemic acute
ischemic stroke patients
within 12 hours of
symptom onset ATHERSYS Double blind,
randomized, placebo
controlled phase 2
safety & efficacy trial
of Multistem in adults
with ischemic stroke Athersys, Inc. To determine the safety
and efficacy of
MultiStem in subjects
with ischemic stroke CLEAR III
Clot Lysis: Evaluating
Accelerated Resolution
Of intraventricular
hemorrhage - Phase III
John Hopkins
University
supported by
NIH ATACH II Antihypertensive
Treatment of Acute
Cerebral Hemorrhage University of
Minnesota
supported by
NINDS Major Exclusion Criteria Contact Information TIA or minor stroke NIHSS 0-3 Age >18 To be enrolled within
12 hours of symptom
onset On clopidogrel, any
antiplatelet or
anticoagulants at time
of symptom onset Call hospital operator 717 531 8521 and ask
for research coordinatorKim Hitz to be paged. NIHSS 3-7 with mRS
0 or NIHSS 8-22 with
mRS 0-1 Type II Diabetic with
glucose >110 or nondiabetic with a
glucose >/=150 Age > or =18 Cortical stroke with a
volume of 5-100ml Age 18-83 NIHSS 8-20 mRS 0-1 Dialysis patients Diabetes Type I Call hospital operator 717 531 8521 and ask
for research coordinatorDeborah Hoffman to be
paged on pager 2613 Seizures History of cancer Call hospital operator 717 531 8521 and ask
for research coordinatorDeborah Hoffman to be
paged on pager 2613 Clotting disorder No EVD needed ICH >30cc Call hospital operator 717 531 8521 and ask
for research coordinatorDeborah Hoffman to be
paged on pager 2613 GCS <5 SBP <180 on arrival at
study site and does not
rise above SBP 180 Call hospital operator 717 531 8521 and ask
for research coordinatorDeborah Hoffman to be
paged on pager 2613 Major Inclusion
Criteria ISCHEMIC STROKE STUDIES HEMORRHAGIC STROKE STUDIES To test the efficacy of
Age 18-80 more rapid
mRS 0 or 1 intraventricular clot
Must be enrolled
resolution by clot
within 72 hours of
drainage plus
onset intraventricular rt-PA. ICH < or =30cc IIIrd or IVth
ventricles occluded Requires an EVD The primary aim of the
Must be enrolled by
study will be to measure
4.5 hrs post onset of
if intensive SBP
symptoms treatment (SBP ≤140
SBP>180 mmHg) is better than
ICH/IVH/IPH <60cc standard SBP treatment
Age >18 (SBP ≤180 mmHg) Upcoming Events
event
location
datescontact info
Capital Region Stroke
Harrisburg, PA
Oct 2-3, 2014
PennStateHershey.org/ce
4
description
This event features presentations
and discussions related to the care and treatment of stroke patients.
U.Ed. MED 14-3741 NEU