243
-Ea st As ia nN eu ro lo gy Fo ru mE AN F
EANF-5
Quality improvement of Acute Stroke Care in Taiwan
Taipei Veteran General Hospital, Hsinchu Branch, Taiwan
○Jiann-Shing Jeng
Since the NINDS tPA trial in 1995, the attitude for acute stroke care has changed dramatically. Intravenous tPA stands the most-recommended and first-line treatment for patients with acute ischemic stroke (AIS) within 3 hours after stroke onset. Shorter onset to tPA treatment time is associated with reduced mortality and better outcome. To achieve timely and successful thrombolytic therapy, earlier hospital presentation and reduced intra-hospital delay are essential. Therefore, improvement of systems-based practice to enhance delivery of acute stroke care should be established.
However, intravenous tPA for AIS patients was not paid high attention during 1995-2005 in Taiwan. From the Taiwan Stroke Registry, ＜3% of AIS patients can receive tPA therapy in 2006-08. To improve acute stroke care quality, several activities have been conducted in Taiwan. First, multi-center stroke registry since 2006, ＞50 hospitals with ＞100,000 patients were registered till 2015, and many treatment and outcome variables can be analyzed. Second, monitoring and improving stroke care quality measures.
In 2009, we performed Breakthrough Series-Stroke activity, a nationwide, multi-center activity in Taiwan. 14 stoke quality measures, adopted from the GWTG-Stroke, were used to evaluate the AIS care quality. The rates of tPA increased from 1.2% to 4.6%, and door-to-needle £60 minutes improved from 7.1% to 50.8%. Third, the implementation and accreditation of emergent rescuer responsive hospitals to major emergent diseases, including acute stroke, has been conducted since 2009. Fourth, the payment for evaluation of thrombolysis and thrombectomy devices have been covered by the national health insurance since 2016. Now, we still face many obstacles, particularly after the success of endovascular treatment for AIS in 2015. Short of interventionists, urban rural health inequality, a low population awareness of acute stroke, and lack of acute stroke care network are required for improvement.
《Curriculum Vitae》
YEAR OF BIRTH: 1963 EDUCATION:
1989 M.D. Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
2005 Ph.D. Department of Epidemiology, Graduate School of Public Health, National Taiwan University, Taipei, Taiwan
POSTGRADUATE TRAINING:
1989-1994 Resident, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan 1998 Postdoctoral Research Fellow, Neurological Institute, Columbia-Presbyterian Medical
Centre, New York, U.S.A PRESENT APPOINTMENT:
Since 1994 Attending Staff, Department of Neurology, National Taiwan University Hospital Since 2009 Director, Stroke Center ICU, National Taiwan University Hospital
Since 2014 Professor, Department of Neurology, College of Medicine, National Taiwan University FIELD OF INTEREST: Acute stroke, Cerebrovascular disease, Neurocritical care, Neurosonology,
Neuroepidemiology PUBLICATION: 189 (till 2016/03)
EANF-6
Acute Phase Management of Stroke
Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong
○K.S. Lawrence Wong
For the acute treatment of ischemic stroke, TIME IS BRAIN. A delay of one minute would cost the death of an estimated 1.9 million neurons and 12km ofaxons. The use of intravenous tPA and intra-arterial thrombectomy have been shown to improve the outcomes of patients substantially.
However, there are still numerous obstacles to shorten to symptom-to-door time, door-to-needle and door-to-table time.
Public education to promote how to recognize stroke symptoms has been used successfully to hasten the reaction of patients to call 911. The advertisement of the FAST program is simple and effective in this regard. Quick mobilization of special ambulance with professionally trained paramedics, some even equipped with a mobile CT scan, should be a standard. Pre-hospital arrival notification of the stroke team and CT suite will reduce the door-to-needle time substantially. Use of telemedicine allows more centers to give tPA despite lack of on-site specialist. This is important in Asia because of the vast territories and lack of resources in many countries.
《Curriculum Vitae》
Ka Sing Lawrence WONG Chief of Neurology
Mok Hing Yiu Chair Professor of Medicine The Chinese University of Hong Kong
Professor K.S. Lawrence Wong received his undergraduate and medical training from the University of New South Wales in Sydney.
He completed a Neurology Residency Program at the Prince of Wales Hospital, Hong Kong.
Professor Wong is the Secretary of the World Stroke Organization, Secretary of the Asian Oceanian Association of Neurology. Currently he is an Associate Editor of the journal Stroke (American Heart Association) and Deputy Editor of the journal Journal of Neurology, Neurosurgery and Psychiatry (BMJ). He also serves or had served as member of the editorial board for JNNP, European Journal of Neurology, Journal of the Neurological Sciences, Chinese Medical Journal and Journal of Neuroimaging.
His major research interests include various aspects of cerebrovascular disease such as intracranial atherosclerosis, neurosonology, epidemiology, cerebral blood flow, atrial fibrillation and clinical trials for treatment and prevention of stroke in Asians. He co-ordinates many international clinical trials in Asia and has published more than 400 peer-reviewed original articles.
East Asian Neurology Forum EANF：How to manage stroke: the first priority in Asia（Session 2）
5月20日（金） 14：25～15：45 第11会場(神戸国際会議場3・4F 国際会議室)
Ea st As ia nN eu ro lo gy Fo ru mE AN F
EANF-5
Quality improvement of Acute Stroke Care in Taiwan
Taipei Veteran General Hospital, Hsinchu Branch, Taiwan
○Jiann-Shing Jeng
Since the NINDS tPA trial in 1995, the attitude for acute stroke care has changed dramatically. Intravenous tPA stands the most-recommended and first-line treatment for patients with acute ischemic stroke (AIS) within 3 hours after stroke onset. Shorter onset to tPA treatment time is associated with reduced mortality and better outcome. To achieve timely and successful thrombolytic therapy, earlier hospital presentation and reduced intra-hospital delay are essential. Therefore, improvement of systems-based practice to enhance delivery of acute stroke care should be established.
However, intravenous tPA for AIS patients was not paid high attention during 1995-2005 in Taiwan. From the Taiwan Stroke Registry, ＜3% of AIS patients can receive tPA therapy in 2006-08. To improve acute stroke care quality, several activities have been conducted in Taiwan. First, multi-center stroke registry since 2006, ＞50 hospitals with ＞100,000 patients were registered till 2015, and many treatment and outcome variables can be analyzed. Second, monitoring and improving stroke care quality measures.
In 2009, we performed Breakthrough Series-Stroke activity, a nationwide, multi-center activity in Taiwan. 14 stoke quality measures, adopted from the GWTG-Stroke, were used to evaluate the AIS care quality. The rates of tPA increased from 1.2% to 4.6%, and door-to-needle £60 minutes improved from 7.1% to 50.8%. Third, the implementation and accreditation of emergent rescuer responsive hospitals to major emergent diseases, including acute stroke, has been conducted since 2009. Fourth, the payment for evaluation of thrombolysis and thrombectomy devices have been covered by the national health insurance since 2016. Now, we still face many obstacles, particularly after the success of endovascular treatment for AIS in 2015. Short of interventionists, urban rural health inequality, a low population awareness of acute stroke, and lack of acute stroke care network are required for improvement.
《Curriculum Vitae》
YEAR OF BIRTH: 1963 EDUCATION:
1989 M.D. Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
2005 Ph.D. Department of Epidemiology, Graduate School of Public Health, National Taiwan University, Taipei, Taiwan
POSTGRADUATE TRAINING:
1989-1994 Resident, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan 1998 Postdoctoral Research Fellow, Neurological Institute, Columbia-Presbyterian Medical
Centre, New York, U.S.A PRESENT APPOINTMENT:
Since 1994 Attending Staff, Department of Neurology, National Taiwan University Hospital Since 2009 Director, Stroke Center ICU, National Taiwan University Hospital
Since 2014 Professor, Department of Neurology, College of Medicine, National Taiwan University FIELD OF INTEREST: Acute stroke, Cerebrovascular disease, Neurocritical care, Neurosonology,
Neuroepidemiology PUBLICATION: 189 (till 2016/03)
EANF-6
Acute Phase Management of Stroke
Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong
○K.S. Lawrence Wong
For the acute treatment of ischemic stroke, TIME IS BRAIN. A delay of one minute would cost the death of an estimated 1.9 million neurons and 12km ofaxons. The use of intravenous tPA and intra-arterial thrombectomy have been shown to improve the outcomes of patients substantially.
However, there are still numerous obstacles to shorten to symptom-to-door time, door-to-needle and door-to-table time.
Public education to promote how to recognize stroke symptoms has been used successfully to hasten the reaction of patients to call 911. The advertisement of the FAST program is simple and effective in this regard. Quick mobilization of special ambulance with professionally trained paramedics, some even equipped with a mobile CT scan, should be a standard. Pre-hospital arrival notification of the stroke team and CT suite will reduce the door-to-needle time substantially. Use of telemedicine allows more centers to give tPA despite lack of on-site specialist. This is important in Asia because of the vast territories and lack of resources in many countries.
《Curriculum Vitae》
Ka Sing Lawrence WONG Chief of Neurology
Mok Hing Yiu Chair Professor of Medicine The Chinese University of Hong Kong
Professor K.S. Lawrence Wong received his undergraduate and medical training from the University of New South Wales in Sydney.
He completed a Neurology Residency Program at the Prince of Wales Hospital, Hong Kong.
Professor Wong is the Secretary of the World Stroke Organization, Secretary of the Asian Oceanian Association of Neurology. Currently he is an Associate Editor of the journal Stroke (American Heart Association) and Deputy Editor of the journal Journal of Neurology, Neurosurgery and Psychiatry (BMJ). He also serves or had served as member of the editorial board for JNNP, European Journal of Neurology, Journal of the Neurological Sciences, Chinese Medical Journal and Journal of Neuroimaging.
His major research interests include various aspects of cerebrovascular disease such as intracranial atherosclerosis, neurosonology, epidemiology, cerebral blood flow, atrial fibrillation and clinical trials for treatment and prevention of stroke in Asians. He co-ordinates many international clinical trials in Asia and has published more than 400 peer-reviewed original articles.
East Asian Neurology Forum EANF：How to manage stroke: the first priority in Asia（Session 2）
5月20日（金） 14：25～15：45 第11会場(神戸国際会議場3・4F 国際会議室)
244
-Ea st As ia nN eu ro lo gy Fo ru mE AN F
EANF-7
Botulinum Toxin Therapy in Post-Stroke Spasticity: The Forward Steps
University of Santo Tomas Hospital, Manila, Philippines
○Raymond Lotilla Rosales
Post stroke spasticity (PSS) has a 19％ prevalence at 3 months, reaching up to 38％ in one year for first ever strokes. PSS may become disabling, leading to significant functional impairment that ranges from loss of mobility, loss of dexterity and muscle pain, ultimately resulting to poor quality of life. Pooled systematic studies on PSS prove that Botulinum toxin-A (BoNTA) has superior efficacy and safety and has become the first line management, in tandem with physiotherapy. Through time, not only do neural mechanisms of muscle hypertonus occur, but that biomechanical changes at affected joint movers do worsen with the evolving events in spasticity . Most studies use BoNTA in the chronic stage, or Established Spasticity (＞6months from onset of PSS), which is perhaps why functional benefits were not achieved. Furthermore, complications of spasticity like co-contractions, dystonia and contractures may have already set-in. Early intervention with BoNTA (＜3 months from onset of PSS, and non-progressive brain lesions) at the stage of Evolving Spasticity, has been shown in 3-upper limb and 2-lowerlimb spasticity clinical trials. With peripheral BoNTA injection, a dual blockade of the extrafusaland intrafusal muscles occur, during the process of chemodenervation. Thus, the central motor programs at segmental and suprasegemental levels, may be modified by BoNTA via a sensory modulation from muscle spindle denervation. Together with task-oriented physiotherapy and retraining, BoNTA could possibly be considered an "
information-rich" intervention that promotes brain neuroplasticity. To optimize BoNTA efficacy, a "best-responder" population should be sought in spasticity, while the specialist employs smart goals that engage the patient, therapists and care-givers.
《Curriculum Vitae》
RLR is Professor and Faculty (Dept. of Neurology and Psychiatry) of the University of Santo Tomas (UST, Manila), finishing his BS and MD from the same institution. He obtained his PhD from Kagoshima University Graduate School of Medicine, through Monbusho and JSPS scholarships. Had Neuromuscular fellowship from the now Dept. of Neurology and Geriatrics of Kagoshima University (Japan);
Joined Clinician Programs at Mayo Clinic EMG laboratory (Minnesota) and at Dystonia Clinic, Columbia University (New York) . He was former President of: Philippine Neurological Association;
Movement Disorders Society of the Philippines; and Philippine Society of Neuro-Rehabilitation. Currently, he is Vice President of the Asian and Oceanian Myology Center, and the AOS Secretary, International Parkinson and Movement Disorder Society. He convened Master classes in Spasticity, Neuropathic Pain and Botulinum toxin therapy. He is an Academic Editor (Medicine Open Access, USA), and Editorial board member of the Nature Parkinson’s Disease Journal and the Journal of Movement Disorders. He edited 3 books, authored chapters, and published > 100 articles in peer-reviewed journals. He received various Rector’ s research and international publication awards from UST. He is Chief of Neurology of Metropolitan Medical Center, and staff of Clinical Neurophysiology and Movement Disorders of St. Luke’ s Medical Center (INS).
East Asian Neurology Forum EANF：How to manage stroke: the first priority in Asia（Session 2）
5月20日（金） 14：25～15：45 第11会場(神戸国際会議場3・4F 国際会議室)
245
-Ea st As ia nN eu ro lo gy Fo ru mE AN F
座長：
松本昌泰(広島大学大学院医歯薬保健学研究院 脳神 経内科学)
鈴木則宏(慶應義塾大学病院 神経内科)
≪ねらい≫
脳卒中治療ガイドライン2015が6月に発刊された．脳卒中 の一次予防，急性期治療について血圧コントロールはじめエ ビデンスに基づいた多くの改訂がなされた．脳梗塞・TIAの 分野でも血栓溶解療法について脳出血については急性期血 圧コントロールなど，くも膜下出血の領域では血管内治療に ついてなど全領域最新のエピデンスに基づいてガイドライ ンの改訂がなされた．
本シンポジウムでは，ガイドラインの改訂ポイントと改訂 後に既に展開しつつある新たなエピデンスについてディス カッションを行う．
G-01-1
脳卒中治療ガイドライン2015の改訂点と その後の展開
-脳卒中一般-東京女子医科大学病院 神経内科学
○北川一夫
2015に改訂された脳卒中治療ガイドラインでは 脳卒中一般 の項目は 管理，SCU，発症予防，地域連携の4項目に分けられ ている．管理では 脳卒中急性期に無呼吸低呼吸指数を勘案し た非侵襲的人工呼吸器管理の導入が推奨された．また神経症状 が安定している症例では発症前から服用している降圧薬などを 発症後24時間以後に再開することを考慮しても良いことなどが 推奨された．栄養に関しては 脳卒中発症後7日以上十分な経 口摂取が困難と判断された患者では発症早期から経鼻胃管によ る経腸栄養が推奨された．体位については低酸素血症 気道閉 塞 誤嚥の可能性のある症例では15－30度の頭位挙上を考慮し てよいことが記載された．発症予防の項目は危険因子の管理と ハイリスク群の管理に分類され，前者では高血圧 糖尿病 脂 質異常症 心房細動 喫煙 飲酒 炎症マーカー 後者には睡 眠時無呼吸 メタボリックシンドローム 慢性腎臓病 に分類 されている．最も変更されたのは心房細動の項目にCHADS2ス コアを指標に非ビタミンK阻害経口抗凝固薬（NOAC）の記載 が加わったことである．CHADS2スコア1点の場合でもNOAC による抗凝固療法が推奨されている．また高血圧の項目では後 期高齢者での管理目標が緩和され150/90mmHg未満とされてい る．また血圧変動の抑制が脳卒中予防に有効な可能性があり 血圧変動抑制の観点からカルシウム拮抗薬が推奨されている．
危険因子の項目では今回あらたに炎症マーカーが追記された．
高感度CRP濃度は血管炎症を反映するとされ アテローム血栓 症リスクの高い患者では高感度CRP濃度測定が推奨されてい る．地域連携の項目は今回あらたに追加された．市民への啓発 活動の推奨 救急隊員への病院前脳卒中評価ツールの使用 専 門医が不在の地域での遠隔医療システムの導入 病院間搬送
（Drip, Ship and Retrieve法） 急性期から回復期 慢性期にか けての切れ目のない医療を提供するための地域連携パスの活用 などが推奨されている
《略歴》昭和58年 3 月 大阪大学医学部医学科卒業
昭和58年 7 月 医員（研修医）（大阪大学医学部附属病院）
59年 7 月 医員（研修医）（国立大阪南病院）
61年 7 月 大阪大学医学部研究生 （内科学第一教室）
平成 2 年11月 米国コロンビア大学医学部研究員
5 年12月 医員（大阪大学医学部附属病院）（第一内科）
9 年10月 大阪大学助手（内科学第一教室）
18年 8 月 大阪大学医学部附属病院助手 (脳卒中センター) 19年 4 月 大阪大学大学院医学系研究科准教授（神経内科学）
22年 4 月 大阪大学医学部附属病院脳卒中センター 副センター 26年 4 月 東京女子医科大学医学部神経内科学 教授・講座主任長兼任