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Spokane County EMS

New Interventions for Acute Stroke

Paula Eboli, MDDepartment of Neurosurgery

Rockwood Clinic, Deaconess Hospital

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Overview

• Introduction• New Approaches to hemorrhagic Strokes• New Approaches to Ischemic Strokes

– LVO strokes• Case examples• Conclusion• Questions

Spokane County EMS

New Approaches to hemorrhagic Strokes

Paula Eboli, MDDepartment of Neurosurgery

Rockwood Clinic, Deaconess Hospital

Introduction• Non traumatic ICH is a major public health problem• Is the most common type of hemorrhagic stroke

– 4 times more common than subarachnoid hemorrhage– 15% of all strokes

• Annual incidence of 10–30 per 100 000 population• Accounting for 2 million (10–15%)of about 15 million strokes worldwide each year• Hospital admissions for intracerebral hemorrhage increased by 18% in the past 10

years– Probably because of increases in the number of elderly people– Lack of adequate blood-pressure control– Increasing use of anticoagulants, thrombolytics, and antiplatelet agents

• Intracerebral hemorrhage commonly affects – Cerebral lobes– Basal ganglia– Thalamus– Brainstem (predominantly the pons)– Cerebellum

• Mortality rates are as high as 40% to 50%• When associated with IVH mortality rates are between 50% and 80%

Pathophysiology• Hemostasis is initiated by local activation of hemostatic pathways and

mechanical tamponade• About 73% of patients assessed within 3 h of symptom onset have some

degree of hematoma enlargement• Most hematoma enlargement occurs within 3 h• Although enlargement can occur up to 12 h after onset• Up to 35% have clinically prominent enlargement

A. Initial hematoma B. Expansion 2.5h C. Progression 3.5h D. Stabilization 4.5h

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Clinical Presentation• Symptoms are related to the size and location of hematoma• Classic presentations

– Rapid-onset focal neurological deficits– Decreased consciousness– Signs of brainstem dysfunction

• Neurological deterioration is common before and during hospital admission

– Hematoma enlargement– Worsening of edema

• Descriptors of disease severity are predictive of early death– Age– Initial score on the Glasgow coma scale (GCS)– Hematoma volume– Ventricular blood volume– Hematoma enlargement

• CT scanning is the first-line diagnostic approach

• MRI with gradient echo can detect hyperacute ICH

• CTA is needed to diagnose secondary causes, aneurysms, arteriovenous malformations, dural venous thromboses, and vasculitis

• If suspicious CTA, diagnostic cerebral angiogram is recommended

• MRI can also identify secondary causes such as cavernous malformations, although their sensitivity in the acute phase is not well established

Diagnosis Differential diagnosis 24 yo.

Management

• ICH is a medical emergency• Rapid diagnosis and attentive management is crucial• More than 20% of patients will experience a decrease in the GCS of 2 or

more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the ED

• Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival

• A single-center study found that prolonged patient stays in the ED lead to worse outcomes

– Rapid admission to a stroke unit or neuroscience intensive care unit – Early management while the patient is awaiting this bed

• Urgent treatment of time-sensitive issues including BP lowering and reversal of coagulopathy should be initiated in the ED

Spokane County EMS

New MIS Technologies for ICH Evacuation

Paula Eboli, MDDepartment of Neurosurgery

Rockwood Clinic, Deaconess Hospital

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• Received FDA in 2014 • Cranial access burr hole or mini

craniotomy• Evacuation is performed under continuous

endoscopic visualization under stereotactic guidance

• low-profile wand for aspiration and vibrational element to break down the hemorrhagic products

Apollo System

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• It’s placed through a small craniotomy.

• The sheath is stereotactically placed into the distal aspect of the clot along the longest axis of the hematoma.

• The obturator is removed, and the hemorrhage can be resected either with

– Standard suction– Myriad handpiece

• Visualization -Microscope or exoscope

BrainPathThe Myriad Handpiece

The BrainPathsheath

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• 81-year-old male • PMH. Hypertension• Was found down at a law

office • He was nonverbal and

aphasic upon arrival• SBP was 185/106• PE

– PERL– Unable to assess facial

symmetry– Doesn't follow commands– RUE Flexion– LUE Spontaneous

antigravity– RLE Triple flexion– LLE Withdrawal

Case 1 Left parietal craniotomy for evacuation of ICH

14Mental status did not improve much. DC to SNF on

a puree diet

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• 54 yo male• Chronic alcohol abuse• Was just recently admitted for

alcohol withdrawal and was discharged same day

• Found down • Lethargic and not speaking,

intubated for airway protection and transferred for higher level of care

• PE– Intubated, not following

commands– Pupils 3mm bilaterally

reactive– RUE flex– RLE triple flex– LUE and LLE moving

spontaneously antigravity

Case 2 Admission CT/CTA

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Left temporoparietal craniotomy for ICH evacuationStereotactic volumetric guidance with IGS system

17PE: Opens eyes to voice, PERRLA, LUE flexing,LLE

withdraws,RUE minimal movement to stim RLE triple flexionSpokane

County EMS

Interventions for Acute Ischemic Stroke

Paula Eboli, MDDepartment of Neurosurgery

Rockwood Clinic, Deaconess Hospital

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• 1995 - IV-tPA first available FDA approved treatment for AIS

• Neurothrombectomy device - defined by the FDA as a device intended to retrieve or destroy blood clots in the cerebral neurovasculature by mechanical, laser, ultrasound technologies, or combination of technologies

• 2004 - Merci® retriever was the first endovascular device to receive FDA clearance• 2007- Penumbra System® was cleared by the FDA • 2012 - the FDA approved two new devices

Trevo Pro® and Solitaire® stent retrievers after they were shown to have superior rates of recanalization when compared to the Merci

Introduction

Approach to a LVO stroke

Number Needed to Treat (NNT) to see benefit• 40 pts. Thrombolytic for STEMI within 6 hours to prevent death• 10 pts. Endarterectomy for symptomatic carotid artery stenosis to prevent

stroke• 3 pts. Brain Artery Embolectomy to see better outcome at 90 days• 4 pts. Brain Artery Embolectomy To achieve independence at 90 days

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• Class I; Level of Evidence A– Patients should receive endovascular

therapy with a stent retriever if they meet all the following criteria

– Prestroke mRS score 0 to 1– Acute ischemic stroke receiving

intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies

– Causative occlusion of the internal carotid artery or proximal MCA (M1)

– Age ≥18 years– NIHSS score of ≥6– ASPECTS of ≥6– treatment can be initiated (groin

puncture) within 6 hours of symptom onset

• Class IIa; Level of Evidence C– Patients who have

contraindications to intravenous r-tPA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable

– Patients who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries

– Patients <18 years of age with acute ischemic stroke

– Patients who have prestroke mRSscore of >1, ASPECTS <6, or NIHSS score <6 and causative occlusion of the internal carotid artery or proximal MCA (M1)

Spokane County EMS

Endovascular mechanical thrombectomydevices

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• The Penumbra system (Penumbra Inc., CA, USA) presents another approach to mechanical thrombectomy

• This system places a reperfusion catheter proximal to the clot

Penumbra system • ADAPT technique • Utilizes a proximal approach to the

target occlusion from which a large aspiration catheter suctions out thrombus with minimal distal emboli

• 56 year old man with a history of heart failure, A fib, Pacemaker, renal insufficiency

• Ejection fraction 12%• Creatinine 2.4• ASPECTS score 7• Acute onset left hemiplegia, dysarthria,

neglect• Admission NIHSS 12• Received IV tPA 2 hours post onset of

symptoms

Superior right M2 occlusion

ACE clot engagement

Baseline Post ThrombectomyJudging TICI based on AP alone is inadequate. The distinction Judging TICI based on AP alone is inadequate. The disti

between TICI 3 and TICI 2b is better made on lateral inctiondisti

al al angio

NIHSS - 12 NIHSS - 0Groin n Admission CT 24 hour CT

• Trevo device (Stryker)• First device to surface in this group

in Europe in 2010 • August 2012, the FDA granted

clearance for use in patients with acute ischemic stroke

Stent retrievers• The Solitaire (Covidien/Medtronic)• In March 2012, US FDA granted

approval

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• Visible Under Fluoroscopy• Size 3,4, and 6mm diameter

Trevo vs. Solitaire

• Size of 4 mm and 6 mm diameters

ble Under Fluoro f 4 d 6

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Case #1• 81-year-old man • Presented with acute onset of

aphasia and right-sided hemiplegia

• Received intravenous tPA• NIH stroke scale score was 23

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CTA. L M2 occlusion

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CT Perfusion

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Cerebral angiogram

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4 x15 Solitaire thrombectomy device (1pass)

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Full revascularization TICI 3

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Physical Exam at dischargeAwake, alert. MS intact to conversation. CN II-XII intact. Motor full bilateral UE,

full strength bil LE symmetrically. Sensation intact throughout

Blood flow / Blood volume mismatch

CT 6 hours post

Strict BP Control with CT showing stainingBP < 140

Post-procedural management

• If TICI 3, maintain normal blood pressure range SBP 100-140– Avoid hypertension to minimize reperfusion

hemorrhage• If TICI 2a or 2b, may still be dependent on collaterals, so

keep blood pressure and blood volume up, SBP 120-160

• Higher TICI 3 rate• Faster technique• Better outcomes• Less embolic sequelae• With Level 1A evidence that embolectomy has better

outcomes this is now the standard of care for Large Vessel Occlusion.

• Patient transport to centers that can provide this procedure should be expedited

Conclusions

Hi h TIMechanical

CI 3 tCI 3al Thrombectomyy lessons

Spokane County EMS

THANK YOU

Special thanks to

Sheila Crow

Stitchin’ Dreams Embroidery

wcsocrow@yahoo.com

For providing our Secret Question prize

Questions?

Contact: Samantha Roberts509-242-4264

1-866-630-4033robertss@inhs.orgFax: 509-232-8344

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