General Considerations for EVT
"General Considerations for EVT" Flow Chart:
Overall, for all vessel occlusions amenable for EVT, a discussion with INR is recommended. "General Considerations for EVT" follows a colour coding:
- Green boxes are "signposts" of criteria to consider for EVT: baseline function, clinical, radiographic, and timing (last seen well) characteristics of the patient.
- Purple boxes are consideration elements that warrant further discussion with INR as these patients do not automatically get considered for EVT.
- Blue boxes represent patients that require an individualized approach.
- The Yellow box represent patients that have met all previous criteria (Pre-stroke status, Signs and Severity of Deficit, Imaging criteria) and are candidates for EVT.
- Please note detailed imaging criteria, listed below ("CSBPR 2018 Guidelines - Imaging Criteria for EVT") for patients within 6hrs and beyond 6hrs after stroke onset.
CSBPR 2018 Guidelines - Imaging Criteria for EVT
DAWN / DEFUSE 3 Criteria - to be used for > 6hr for EVT Consideration
RAPID Training (www.irapid.com/training-rapid)
Late EVT Window, Greater than 6 hours (6-24Hrs)
- ICA or MCA-M1 occlusion (carotid occlusions can be cervical or intracranial; with or without tandem MCA lesions) by MRA or CTA AND
- Target Mismatch Profile on CT perfusion or MRI (ischemic core volume is < 70 ml (CBF<30), mismatch ratio is >/= 1.8 and mismatch volume* is >/= 15 ml) Alternative neuroimaging inclusion criteria (if perfusion imaging or CTA/MRA is technically inadequate): If CTA (or MRA) is technically inadequate:
- Tmax>6s perfusion deficit consistent with an ICA or MCA-M1 occlusion AND Target Mismatch Profile (ischemic core volume is < 70 ml, mismatch ratio is >1.8 and mismatch volume is >15 ml as determined by RAPID software)
DAWN criteria (core measured CBF<30)
- 0-<21 cc core infarct and NIHSS ≥ 10 (and age ≥ 80 years old)
- 0-<31 cc core infarct and NIHSS ≥ 10 (and age < 80 years old)
- 31 cc to <51 cc core infarct and NIHSS ≥ 20 (and age < 80 years old)
Lastly a word of caution. ALWAYS ensure you look at NCCT to assess hypo-density and correlate this with CBF core recalling that you may have a sub-acute infarct with luxury perfusion (therefore CBF>30 i.e. not showing as core on threshold to CBF map).
Graphic/table reference: Stroke, G. A., 2018. (n.d.). Use of Imaging to Select Patients for Late Window Endovascular Therapy. Am Heart Assoc. http://doi.org/10.1161/STROKEAHA.118.021011.)
ACT-FAST: 6-24 H Protocol
RAPID Software Resources
Post-TPA ICU Expansion
High observation for specific post-TPA patients meeting below criteria
After a code stroke resuscitation, the patient needs a monitored bed for neurologic monitoring.
On the B4 Stroke Unit, there will ultimately be several types of beds.
- Post-TPA ONLY - Level 1 (total 9 beds, currently 6, MRP = Orange Team) -these beds can provide every to every 2 hourly neuro vital signs, there is cardiac monitoring as well, there are no arterial lines, there are no infusions of vasoactive agents including pressors or infusions of labetalol, however certain medications requiring cardiac monitoring such as phenytoin, amiodarone can be provided. Other medications can be given IV, but and intermittent dosing.
- Post-TPA and/or Post-EVT Level 2 (total 6 beds, currently 2, MRP = ICU) - these are equivalent to B5ICU beds, these patients can have vasoactive agents, have cardiac monitoring, and can have arterial lines, therefore if the patient requires infusion of vasoactive agents, which typically does require arterial line monitoring, these patients can go to this bed.
Definitions of ICU "levels":
- Level I = observation, no vasoactive infusions, no BiPAP
- Level II = observation, vasoactive infusions, invasive arterial/BP measurement, non-invasive ventilation - i.e. BiPAP
- Level III = all advanced ICU measures, including above, and mechanical ventilation
Repatriation and Consultation Notes
When patients are repatriated, at times we may want to fax completed notes, beyond the written consultation note. For this purpose, the following ED Fax numbers can be utilized to fax the report:
Hospital ED / FAX #
North York General / 416-756-6793
Mackenzie Health / 905-883-2138
Toronto Western / 414-603-5288
Scarborough and Rouge- General Site / 416-431-8164
Scarborough and Rouge-Centenary Site / 416-281-7455
Other Key Access Points:
ICU Fellow #s - direct
ICU CONSULT RESIDENT - 88111
CRCU blue 88197
CRCU green 88118
B5ICU 88112 (AM) Overnight 88114 (4PM-7AM M-F, and W/E) - During COVID-19, 88112 for B5ICU and B4ICU Level 2
Rapid Response 7887 - Rapid RN direct access Line
M2 extended ICU 7811
Neuroradiology fellow 1404