CESN EVT TOOLKIT

Journey to Recovery After Stroke Resource

Endovascular Therapy

Endovascular Thrombectomy (EVT) is a standard of care for clinical management of ischemic stroke patients. Highly selected patients with large ischemic stroke and large artery occlusion may benefit from EVT up to 24 hours from the time they were last known well, including patients with stroke on awakening.

For additional information on acute stroke management refer to the Canadian Stroke Best Practice Recommendations #5 Acute Ischemic Stroke Treatment 2022 Update.

4-24hr EVT Toolkit for Non-thrombolytic Sites

The EVT Toolkit has been developed to help Central East Stroke Network organizations with the implementation of a Large Vessel Occlusion Stroke Screening Tool (ACT-FAST) and guide the decision making in the eligibility for EVT. The screen has high specificity and reliability for recognizing large vessel occlusions in severe anterior circulation stroke (Zhao et al., 2018).

The toolkit is for community non-thrombolytic hospitals and is intended for use by organizations’ clinicians including, educators, managers, resource nurses, coordinators, nurses and physicians. Each tab contains resources that can be modified for your site as well as district-specific resources.

What is EVT?

EVT is a highly specialized procedure involving the mechanical removal of a clot in the brain. The procedure is performed by specialists with neurointerventional expertise at EVT Centres. The procedure is for patients with large vessel occlusions. Using advanced imaging, a guide wire is introduced into the femoral artery and guided up to and through the clot. The guide wire is removed, and a stent is inserted and deployed. The clot is encapsulated by the stent and then is mechanically removed.

Medtronic Innovation Helps Yoga Mom Survive a Stroke – Click Here to view video clip

Dr. Timo Krings on why he loves helping patients – Krembil Brain Institute – Click Here to view video clip

Time and Teamwork in Stroke Care – Click Here to view video clip

Mechanical Thrombectomy at the Cleveland Clinic – Click Here to view a short video clip that demonstrates how the procedure is done

When should my stroke patient be sent for EVT? What Emergency Doctors Need to Know!

This video (18 min) was developed by Dr. Blair Bigham in collaboration with the Central East Stroke Network. It provides information for emergency doctors who work in hospitals without comprehensive stroke teams, on-call stroke neurologists or neurointerventional programs. The video discusses indications for EVT, various large vessel stroke syndromes, and the steps needed to refer to a neurointerventionalist.

Created by Dr. Blair Bigham MD MSc DTMH FRCPC an Emergency Physician in the Durham Region, Ontario

Screen – Scan – Send: A Primer on Recognizing Large Vessel Occlusion Strokes that may Benefit from Endovascular Therapy

This 18-minute video provides an overview of the initial assessment of someone presenting with stroke-like symptoms (SCREEN), the importance of STAT imaging (SCAN) and contacting CritiCall to speak with the Stroke Endovascular Team and if patient accepted, arrangements to transfer the patient to an EVT centre (SEND).

The video was created in collaboration with Dr. Blair Bigham MD MSc DTMH FRCPC an Emergency Physician in the Durham Region, Ontario. A very special thank-you to all the individuals who participated in the video and to the Videographer at Lakeridge Health for filming.

Additional Resources as outlined in the video include:

TPA Evidence Review (42 min, free online, U. Ottawa “A stroke of luck” Jul 2021): Thrombolytics – A Stroke of Luck

EVT Evidence Review

EVT +/- Lysis: The future of Stroke? Blog on SGEM and ACEPNow:

District Specific Protocols

For hospital specific documents please refer to your organization’s usual process for developing and accessing policies & procedures

Simcoe Muskoka

Click on the image to view the NSM ACT-FAST Stroke Screening Training Video

HKPR

Click on the image or scan the QR code to view the HKPR ACT FAST Screening Educational Video

Lakeridge Health

LH ACT FAST ppt

York

Click on image to view the York ACT-FAST Stroke Screening Training Video

Stroke Assessment Tool - NIH Stroke Scale

Bedside Neurological Assessment of the Stroke Patient

This 13 min video was developed and filmed by the Stroke Network of Southeastern Ontario. Dr. Jin, a stroke neurologist, explains and demonstrates the key elements of a neurological assessment which can be done at the bedside. CLICK HERE to view

National Institutes of Health Stroke Scale (NIHSS) – Training for ED Physicians (no cost)

NIHSS Training Options flyer (created by OREG)
Blue Cloud NIH Stroke Scale International
Apex Innovations – Click Here and scroll to Free Courseware and click on NIHSS button. Enter organization name and create your own account at no cost
Know Stroke: NIH Stroke Scale Booklet
Tips & Tricks poster for the NIHSS (developed by Champlain & West GTA Stroke Networks)

Additional Training Videos:

Neurological Assessment – NIH Stroke Scale (7 min) OSF HealthCare – Illinois Neurological Institute
National Institutes of Health (NIH) Stroke Scale Demonstration (23 min) North Dakota Health & Human Services
Scoring Template – paper copy that can be used to assist with scoring NIHSS

Scoring Tools/apps:

MD+CALC
Lexicomp – subscription required. Some organizations may have subscription to this resource and can access the NIHSS scoring tool
Apple Store – NIHSS Stroke Scale – Inneva Pharma SL (there is an associated cost to purchase app)

Stroke CT/mCTA Imaging Protocol for Endovascular Treatment (version: June 2023)

Transfer to EVT Site

Do not delay calling CritiCall to await local interpretation of imaging.

EVT Transfer Communication Form (version March 10, 2024)

Simcoe

Simcoe_EVT Transfer Communication Form (version March 10, 2024)

Medical Escort

Guidance for Medical Escort Requirements for AIS Patients being Transferred for EVT – this is a new document as of June 14th, 2023. The document was developed in collaboration with the Hyperacute Stroke Steering Committee, the Ontario Base Hospital MAC and the Ontario Association of Paramedic Chiefs.

Patient/Family Education Resources

Simcoe Muskoka

Stroke Information For Patients and Families (Updated 29 February 2024)

HKPR

Patient/Family EVT Information Brochure

Lakeridge Health

Patient/Family EVT Information Brochure

York

Stroke Information for Patients and Families

Quality Improvement Resources

Audit Tool Template (v. January 19, 2023) – identifies mandatory fields that all sites are collecting, but additional fields can be added at site level for quality improvement purposes. Form to be completed on ALL activations.
Stoplight EVT Case Review Template – can be used by organizations to provide feedback to frontline clinicians.
You will need to insert your organization’s logo. With each case/activation enter the date, change the fill colours of the boxes to either red or green to reflect if indicator met and adjust the minutes.

Simcoe Audit Tool

Note: The measurements in red on the audit tool identify what indicator is being measured. You do not need to do anything with them when you are completing the form.