2021 Neurointervention Unit Annual Report

Annual Report 2021

Neurointervention Unit

SERT Institute

Contents

Neurointervention Unit Royal North Shore Hospital

Foreword

Snapshot

Executive Summary

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2021 Highlights

Quality service and care

Improved radiation protection for NI Unit

Neurointervention surgeon completes FLASH program

A new neurointerventinal suite on theatre floor

Staff Updates

2021 Data Summary

Demographics

Patient residence

Neurointerventional procedures

Indication for neurointervention

Emergency stroke cases

Emergency vs elective procedures

In vs out of hours

Emergency and regular list comparison

Acknowledgements

Glossary

Foreword

NI Unit 2021 Snapshot

852 659 13%

We are pleased to present the 2021 Annual Report for the Royal North Shore Hospital Neurointervention Unit. The Neurointervention (NI) Unit managed to maintain the momentum last year, with a major highlight being progression on the relocation of the service into a new purpose-built neurointerventional suite within the operating theatres. This transition has enabled discussions around service planning, factoring in increased activity based on trending data, and future workforce and resource requirements. Throughout 2021, the NI Unit continued to provide excellent care for neurovascular patients from the Northern Sydney Local Health District (NSLHD), Central Coast Local Health District (CCLHD) and other areas across New South Wales (NSW). From 2020 to 2021, the total procedural workload slightly decreased, in contrast to previous years which have seen an increase of 11-13% per year since 2017. We believe this to be affected by the COVID-19 pandemic, resulting in operating list cancellation, bed block and staff furloughs. Despite COVID-19 impacting the community for parts of 2021, we were able to keep emergency activity within the NI Unit going and we would like to extend our thanks to all staff for their efforts in servicing our patients during this time. We have continued our work in research on stroke treatment and the outcomes we have seen in severe stroke patients presenting to Royal North Shore (RNSH) and Westmead Hospitals have been promising. On behalf of the RNSH NI Unit, we would like to thank the Surgical Education Research & Training (SERT) Institute and the Data Analysis and Surgical Outcomes (DASO) Unit for their ongoing support and assistance.

Total procedures performed A total of 852 NI procedures were performed by the RNSH consultants in 2021, this number includes both diagnostic and treatment procedures.

Emergency procedures performed In 2021, the team performed a total of 659 emergency procedures, accounting for a 77% majority of the total workload.

Dr Nazih Assaad Head of Department RNSH Neurosurgery

Acute stroke procedures 13% of the NI Unit workload was for acute stroke procedures.

Research publications 7 research publications were produced during this reporting period.

Dr Brendan Steinfort Consultant RNSH Neurointervention Unit

Neurointervention Unit Annual Report 2021

Executive Summary

2021 Highlights

The biggest highlight for the NI Unit in 2021 was the exciting announcement of funding for the construction of two theatres, and the installation of one biplane angiogram machine in the RNSH operating theatres, with the first stage expected to be completed in August 2022. On top of this, RNSH purchased a Rampart radiation protection system, a conformable radiation protection shield that removes the need for the operator and scrub teams to wear heavy lead radiation garments. The system was trialed in 2021 and will be a welcome addition when installed in 2022. Throughout 2021, the NI Unit worked closely with the Emergency, Medical Imaging, Anaesthetic and Recovery, Neurosurgery, Neurology and Executive departments to expand the Endovascular Clot Retrieval (ECR) service at RNSH. The ECR service hours were extended to 10pm, 7 days a week in 2021, with 86% of ECR pathway activations being treated at RNSH. The team continues to work collaboratively with all these units to reach the goal of extending to a 24/7 ECR service in 2022. Due to the COVID-19 pandemic and resultant operating list cancellations, bed blocks and staff furloughs, the NI Unit’s activity slightly decreased by 1.3% compared to 2020, however this still represents an overall increase of 40.6% since 2017. Combined, digital subtraction angiography (DSA) and emergency neurointerventions were the majority (75.6%) of procedures performed during 2021, with acute stroke treatment representing 12.8%, and non-neuro and elective NI procedures contributing to 11.6% of the activity. During 2021, the NI Unit started recruitment on two Royal North Shore investigator-driven studies. This included a trial on the use of pharmacogenomics selection in neurointervention and also a collaboration with the Neurology Department on the MOSS study – Medium Vessel Occlusion Study, using intra-arterial tenecteplase (TNK). In the same year, the unit also

completed recruitment for a major international study DIRECT SAFE – optimising the treatment of large vessel stroke. This landmark study was published in the medical journal - The Lancet . As a unit, we continued to build on our strong research collaboration, with involvement in the Monitoring Of Stroke Endovascular Services (MOSES) – a neuroimaging repository for acute stroke, and appointed our first Neurointerventional Research Associate. We also contributed to the major international observational study on COVID-19, stroke and subarachnoid haemorrhage with Boston and Emory Universities. The unit has published 7 research articles last year and continue to collaborate with both local and international researchers. Future opportunities to strengthen the service include, identifying beds for neurovascular and acute stroke patients, maximising available theatre time, transitioning to 24/7 ECR service and developing the potential to treat a wider indication for ECR. The unit looks forward to showcasing the first stage of the new neurointerventional suite later this year and is committed to continuing to provide high quality service across the community.

Neurointervention Unit Annual Report 2021

Quality Service and Care Regular clinical and multidisciplinary team meetings are a core component of the Neurointervention Unit to ensure effective service delivery and a high standard of care for all patients.

Endovascular clot retrieval referral form Patients suspected of having an acute ischaemic stroke require multidisciplinary specialised care, which often requires transfer to stroke centres. The initial stages of diagnosis and intervention to restore blood flow to the blocked artery are time critical as endovascular clot retrieval (ECR) needs to be performed as soon as possible for maximum effectiveness. This has led to the development of pathways to allow rapid assessment and minimise delays in commencing early procedural intervention. In 2021, the neurointervention team used organisational data and communication platforms to develop an ECR Referral Form to streamline communication on incoming inter-hospital transfers for ECR. The process for this referral is that the referring centre completes an online survey using the secure database platform, Research Electronic Data Capture (REDCap). The survey data is merged into an email and sent to a secure department Microsoft Teams channel, enabling senior and junior medical staff to access details about the patient’s admission and history prior to their arrival. The timely exchange of critical information has allowed for expedited admission on arrival and this has improved patient outcomes.

Clinical meetings Neurovascular statewide education In 2021, Royal North Shore Neurosurgery and NI Unit developed the first neurovascular education series targeted at registrars and consultants at RNSH, as well as consultants and trainees throughout NSW. The planning and development for this series was undertaken in 2021. The series will invite speakers from Intensive Care Unit (ICU), Haematology, Interventional Neuroradiology (INR), Neurology, and Neurosurgery who have all contributed to a multidisciplinary education program, with some cameo appearances from our graduating fellows and Senior Resident Medical Officer (SRMO). Neurovascular Stroke Multi-Disciplinary Team Clinical consultants and technology upgrade Stroke Multidisciplinary Team (MDT) meeting combined with the Neurology Department. In the MDT meeting, multiple referral hospitals across Sydney (from the Northern Beaches to Nepean) collaborate to review Stroke ECR cases and identify how to improve the quality of patient care. The NI Unit’s vision is to provide multidisciplinary evidence-based stroke care, and has launched a During 2021, the eHealth Unified Conference, Collaboration and Wireless (UCCW) Program supported the NI team by installing new collaboration technology in two rooms at RNSH. These rooms have allowed effective multidisciplinary meetings from a safe distance.

Both rooms are based on the Health Managed Meeting Room standard and were equipped with Microsoft Teams and first-class video conferencing and collaboration solutions. Prior to the installation of these systems, staff had ongoing issues using the standard conferencing technology platforms and equipment, making remote collaboration and meeting attendance difficult. These meetings now have sufficient audio and visual quality to allow for reliable remote attendance which have been a welcomed change in practice.

Neurosurgery nursing staff participating in remote education

Neurovascular MDT remotely collaborating and planning patient care

ECR Referral Form

Neurointervention Unit Annual Report 2021

Rampart radiation protection system

FLASH Program Participants

Improved radiation protection for Neurointervention Unit

Neurointervention surgeon completes FLASH program

In 2021, RNSH purchased a Rampart radiation protection system to be used by the NI Unit. This is a conformable radiation protection shield that removes the need for the operator and scrub team to wear heavy lead radiation protection garments for most procedures. It is estimated that angiographic operating theatre staff have up to a 700% increased incidence of cervical and lumbar spine injury. The installation of this system will not only reduce the risk of injury, but also help staff members who have a variety of spine and other musculoskeletal issues. This is only the second Rampart device installed in Australia and the first to be used in neurointerventional procedures worldwide. The RNSH NI Unit is very thankful for this upgrade and for the prioritisation of workplace safety and staff wellbeing.

In 2021, Dr Alice Ma, a proceduralist within the NI Unit at RNSH took part in the pilot Fostering Leadership Across Systems in Health (FLASH) program. FLASH was designed by a diverse inter-professional team and aims to bridge the gap between clinicians and leaders within the healthcare system, specifically targeting early career consultants, and was developed around the Australian Health Leadership LEADS framework. The program was conducted over a 7-month period, with monthly workshops - this was initially delivered online due to COVID restrictions, but participants were able to enjoy two full-day face to face sessions as restrictions eased. Dr Ma said the program gave her an opportunity to network while learning valuable leadership skills. “It was a great opportunity to network with colleagues at a similar career level,” she said.

“I also gained some insights into leadership and management skills that are not always part of medical training.” As part of the program, Dr Ma spent time shadowing Deborah Willcox, Chief Executive, NSLHD and Dr Adam Rehak, Clinical Director, Division of Surgery and Anaesthesia, RNSH. “Being able to work alongside and shadow leaders like Deb and Dr Rehak was a highlight of the program for me,” she said. Dr Ma said the program would be beneficial to any early-career clinicians looking to develop skills that are not necessarily taught in medical school. “I highly recommend the program to any early-career clinicians as it offers different perspectives on the delivery of medical services and will help develop skills as you take on greater responsibility as a consultant,” she said.

Neurointervention Unit Annual Report 2021

Staff Updates

Rampart radiation protection system

A new neurointerventional suite on theatre floor In 2021, RNSH purchased a Rampart radiation protection system to be used by the NI Unit. This is a conformable radiation protection shield that removes the need for the operator and scrub team to wear heavy lead radiation protection garments for most procedures. It is estimated that angiographic operating theatre staff have up to a 700% increased incidence of cervical and lumbar spine injury. The installation of this system will not only reduce the risk of injury, but also help staff members who have a variety of spine and other musculoskeletal issues. Rampart places a 1mm lead equivalent between teams and scatter radiation. Rampart’s superior protection is extended outside of the lead radiation protection garment’s traditional cover area, protecting the entire body of the operator and the team.t This is only the second Rampart device installed in Australia and the first to be used in neurointerventional procedures worldwide. The RNSH NI Unit is very thankful for this upgrade and for the prioritisation of workplace safety and staff wellbeing.

Neurointervention Unit Annual Report 2021

STAFF UPDATES

Queenie Leung

Konrad Schultz

Blake Giarola

Sundip Udani

Dr Sundip Udani joined the RNSH NI Unit as a fellow in 2021, and has since gone on to neuroradiology consultant work.

Dr Konrad Schultz was a member of the NI Unit as an SRMO for one year during the 2021/2022 clinical year. Dr Schultz undertook his medical degree at the University of Sydney and completed internship and residency in the Hunter New England network. Dr Schultz subsequently commenced radiology training at Prince of Wales Hospital in Sydney in 2022.

Queenie Leung is a neurointensive care nurse with 15 years of experience. She has been working in research in the NI and ICU departments at RNSH. Her previous roles include Stroke CNC at Northern Beaches Hospital, Nurse Educator, Clinical Nurse Educator and Rapid Response Nurse at RNSH. Queenie commenced as the NI Unit Research and Data Officer in July 2021, primarily coordinating the Monitoring Of Stroke Endovascular Services (MOSES) Registry. Queenie strives for evidence- based practice and regularly engages in research and quality improvement projects. She has successfully published an academic paper in the Australian Journal of Neuroscience

Dr Blake Giarola joined the NI Unit for 12 months in 2021, where he gained extensive experience in all aspects of neurovascular intervention. Dr Giarola studied medicine at Flinders University, Adelaide and completed Basic Physician Training at the Royal Adelaide Hospital. Prior to commencing his neurointervention fellowship in 2020 at Royal Prince Alfred Hospital and John Hunter Hospital, Dr Giarola completed Advanced Training in Neurology. Dr Giarola is undergoing his final fellowship year at Liverpool Hospital, and will complete his neurovascular training for the Conjoint Committee for Recognition of Training in Interventional Neuroradiology (CCINR) in 2022.

Lachlan Jackson

Dr Lachlan Jackson joined as a Senior Resident Medical Officer (SRMO) in 2021. During this time, he developed neurological examination skills and the ability to interpret neuroimaging from critically ill acute stroke and cerebrovascular patients. Dr Jackson has also been involved with managing postoperative cerebrovascular pathology in both the acute and longer-term phases of patients’ journeys. Dr Jackson has also written a technical case report on a novel technique for ‘Retrieval of microcatheters entrapped in Onyx during dural arteriovenous fistula embolisation’, and has since been published in the Operative Neurosurgery Journal . Dr Jackson is now a neurosurgery registrar, and hopes to become an open and endovascular dual-trained neurosurgeon. He looks forward returning to RNSH for his training.

Heather Thom

Dr Ryan Mcconnell

Ryan Mcconnell

Dr Ryan McConnell studied medicine at Flinders University in South Australia and completed his specialty radiology training at RNSH. Dr McConnell undertook his provisional fellowship in interventional radiology in 2019, and commenced his INR postgraduate fellowship in 2020 at RNSH. After his fellowship training, Dr McConnell was successful in obtaining registration in the CCINR. He is now a consultant in interventional radiology at Nepean Hospital and is working to expand the neurointerventional capability of this unit. Dr McConnell has appointments as an INR consultant at the Northern Beaches Hospital, and in interventional radiology at RNSH and has recently started his own private practice.

and presented at local and international conferences.

Heather Thom

Heather Thom is a Clinical Nurse Consultant (CNC) in the NI Unit. She has worked in neurosurgery for over 15 years and has a Master in Nursing, Advanced Practice and Graduate Certificate in Health Service Management. Heather is responsible for the coordination of inpatient and outpatient care, development of specialty education resources and support, selected clinical trial coordination, as well as strategic planning and pathway optimisation relating to neurointervention care.

Dr Blake Giarola

Queenie Leung

Dr Lachlan Jackson

Neurointervention Unit Annual Report 2021

2021 Data Summary

Demographics

Procedures performed

Total Patients

Gender and age In 2021, the NI Unit workload included a total of 852 procedures performed which were attributed to 491 patients. Figure 1 shows the gender and age bands of all 491 patients included in this reporting period. The largest proportion of patients (21.8%) were aged between 60-69 years old, and the majority being female patients (53.4%) compared to male patients (46.6%).

Figure 1: Gender and age bands of all patients

Neurointervention Unit Annual Report 2021

Patient residence Figures 2A and 2B provide an overview of the patient distribution across Local Health Districts (LHD) and Local Government Areas (LGA). In 2021, 48.6% of the 491 patients were from outside the Northern Sydney LHD. Within the LHD, the largest proportion of patients (12.3%) resided in the Northern Beaches LGA.

Patient residence (continued)

Figure 2B: Patient distribution across Local Government Areas

Rural and regional LHDs

External to NSW

Local Health District

Australian Capital Territory

Hunter New England 5.8%

0.4%

Mid North Coast

1.5%

Tasmania

0.2%

Western NSW

1.1%

Unknown Address

0.2%

Southern NSW

0.6%

Victoria

0.2%

Figure 2A: Patient distribution across Local Health Districts

Murrumbidgee

0.2%

Neurointervention Unit Annual Report 2021

Procedure types The breakdown of procedure by type during 2021 is shown in Figure 4A and by month in Figure 4B. Combined, DSA and emergency NI represented the majority (75.6%) of the procedure types performed by the unit over this period. Figure 4B shows that there was a high proportion of emergency neurointerventional procedures for May; contributing to the unusually high number of total procedures for this month. It should be noted that the ‘other/non-neuro’ procedure type category includes sclerothrapy, vertebroplasty, lumber puncture, non-neuro angiograms (renal, spinal), nerve block including sphenopalatine ganglion block, and non-neuro embolisation procedures.

Neurointerventional Procedures

Total number of procedures A total of 852 NI procedures were performed by the RNSH NI consultants in 2021, this number includes both diagnostic and treatment procedures.

Figure 3 shows the total number of procedures in 2021 compared to 2020 (n=863) across each month.

In 2020, there was a substantial decrease in procedures in April to May (attributed to the impact of COVID-19 on procedural activity) and a significant increase in numbers for July, August and December when compared to the other months over this period and the same period for 2019.

From 2020 to 2021, the total procedural workload decreased by 1.3%.

Figure 4A: Procedures by type

Figure 4B: Procedures types by month

Figure 3: Total number of procedures in 2021 compared to 2020 across each month

Neurointervention Unit Annual Report 2021

Indication for Neurointervention Of the 852 total NI procedures performed by the unit for this year, 489 were treatment procedures. Figure 5 shows the breakdown of indication for these treatment procedures with 40.5% of these required for the treatment of vasospasm. Notes: • Numbers for emergency and elective neurointerventional cases have been included, and • “Other” indication category includes stenosis, tumour and Middle Meningeal Artery (MMA) embolisation.

Emergency Stroke Cases

Treatment procedures

ECR pathway activation

Acute ischaemic stroke is usually caused by arterial thrombosis or embolus. Endovascular clot retrieval (ECR) aims to remove obstructing blood clots in ischaemic stroke patients who have large vessel occlusions (LVOs); thereby restoring blood flow to the brain and minimising brain tissue damage. Patients suspected of LVOs require rapid assessment, early intervention, and specialised post procedural care. For ECR to be clinically effective, it needs to be performed as soon as possible and to a high standard of procedural excellence. Without this, clinical trials have proven the procedure to be futile. Any patient who presents or is referred to RNSH with an LVO will activate the acute stroke and/or ECR pathway. This includes patients who underwent ECR; had LVOs and underwent DSA (without ECR) or who were transferred for ECR consideration and underwent conservative management. The acute stroke pathway is activated when patients are identified to have acute stroke symptoms. The pathway initiates a rapid neurological assessment by the specialised stroke team, with rapid access neuroimaging needed to make a diagnosis and identify treatment options. The ECR pathway can be activated for select patients with confirmed LVOs, bypassing resuscitation and/or medical imaging, to allow the patient to be transferred directly to the angiography table to minimise treatment delays. In 2021, 138 procedures activated the ECR pathway, representing 16.2% of all INR procedures. This includes procedures performed on confirmed LVO patients, including ECR, IA tPA, and DSA only (due to distal clot migration or inability to access occlusion site). Of the 138 pathway activations, 111 (80.4%) were for treatment and 27 (19.6%) were DSA only.

Figure 5: Indication for neurointervention

Neurointervention Unit Annual Report 2021

Emergency vs Elective Procedures

Figure 7 shows the breakdown of elective versus emergency procedures by indication for neurointervention treatment procedures only (n=489).

Emergency procedures

Elective procedures

The majority of procedures performed by the unit in 2021 were emergency procedures (n=659). Figure 6 shows the breakdown of elective versus emergency procedures by month.

Figure 7: Breakdown of elective vs emergency procedures by month Note: the “Other” indication category includes stenosis, tumour and MMA embolisation.

Figure 6: Breakdown of elective vs emergency procedures by month

Neurointervention Unit Annual Report 2021

In vs Out of Hours

Figure 9 shows that there were no significant differences in the proportion of “Out of Hours” procedures performed across each weekday (Monday - Friday) for 2021.

“In Hours” is defined as Monday to Friday between 8am and 5pm with “Out of Hours” being any time outside of that period.

In hours

Out of hours

Figure 8 shows the breakdown of “In Hours” versus “Out of Hours” procedures by procedure category. As expected, the emergency neurointervention procedure category had the largest proportion (37.0%) of “Out of Hours” procedures.

Figure 9: Breakdown of elective vs emergency procedures by month

Figure 8: Breakdown of “In Hours” versus “Out of Hours” procedures by procedure category

Neurointervention Unit Annual Report 2021

Acknowledgements

Emergency and regular list comparison

Figure 10 shows the breakdown between emergency and regular NI lists across all weekdays (Monday to Friday).

• 487 (57.2%) procedures were performed on the NI allocated list days (Monday, Thursday or Friday between 8am and 5pm). • 365 (42.8%) procedures were performed on the emergency anaesthetic list.

Data Manager Susan O’Donnell

Consultants

Dr Kenneth Faulder Dr Timothy Harrington Dr Alice Ma Dr Brendan Steinfort

Administration Saurabh Sachdeva Lonita Au Yeung

Fellows

Report design and development

Dr Ryan McConnell Dr Blake Giarola Dr Sundip Udani

Nadine Chidiac Kathy Chung Tim Pollicina

Senior Resident Medical Officers

Dr Lachlan Jackson Dr Konrad Schultz

Clinical Nurse Consultant

Heather Thom

Figure 10: Breakdown between emergency and regular NI lists across all weekdays (Monday to Friday)

Neurointervention Unit Annual Report 2021

Glossary

Abbreviation

Definition

CCINR

Conjoint Committee of Interventional Neuroradiology

CNC

Clinical Nurse Consultant

DASO

Data Analysis & Surgical Outcomes Unit

DoSA

Division of Surgery and Anaesthesia

DSA

Digital Subtraction Angiography

ECR

Endovascular Clot Retrieval

ICU

Intensive Care Unit

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INR

Interventional Neuroradiology

LVO

Large Vessel Occlusion

MDT

Multidisciplinary Team Meeting

MMA

Middle Meningeal Artery

Neurointervention

NSLHD

Northern Sydney Local Health District

NSW

New South Wales

Research Electronic Data Capture An online data collection platform to manage online surveys and databases

REDCap

RNSH

Royal North Shore Hospital

SRMO

Senior Resident Medical Officer

Neurointervention Unit Annual Report 2021

Northern Sydney Local Health District Royal North Shore Hospital Reserve Road St Leonards NSW 2065

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www.nslhd.health.nsw.gov.au

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