europeancourseininterventional i neuroradiology i ... in post circ stroke...ivisual fielddefects...

Volker PützDepartment of NeurologyDresden Neurovascular CenterUniversity of Technology DresdenGermany

European Course in InterventionalNeuroradiology

EVT in posteriorcirculation stroke

www.uniklinikum-dresden.de

I I‘m a neurologist

I Lecturerer fees:Daichii Sankyo, Bristol-Meyers Squibb

I Local PI:WAKE-UP, RESPECT-ESUS, ESCAPE-NA1, BASICS

I Study-participation Dresden Neurovasular Center:NAVIGATE-ESUS, PRODAST, RASUNOA-PrimeIMS-3, CLOTBUST-ER, THERAPY

Disclosures


IClinical presentation

IDiagnosis

I Imaging scores

I TreatmentIVT vs. EVTTimeTechnical aspects

3

Outline

www.uniklinikum-dresden.de4

Basilar artery occlusion

I 20% of all ischemic strokes in the posterior circulation

I Basilar artery occlusion: 1% of all ischemic strokes

I Poor clinical prognosis

Schonewille et al., J Neurol Neurosurg Psychiatry 2005; Lindsberg and Mattle, Stroke 2006


Etiology

a. Cardioembolic (40%-55%)

b. In Situ atherosclerotic thrombosis (25%-35%)

c. Embolism from tandem vertebral artery steno-occlusion(10%-30%)

Schulte-Altedorneburg, Cerebrovasc Dis 2004, Baik et al., Radiology 2019

a b c


Clinical symptoms variable

60% prodromal symptoms, stuttering course

Brückmann et al., Stroke 1990; Baird et al., Neurocrit Care 2004


Warning signs

IDecreased LOC

IOculomotor deficits, diplopia

I Anisocoria

IDysarthria

I Visual field defects

I Tetraparesis

I Ataxia

Pfefferkorn et al., J Nervenarzt 2006; Savitz und Caplan, NEJM 2005; Schonewille et al., J Neurol Neurosurg Psychiatry 2005; Hacke et al., Stroke 1988

Radpid diagnosis crucial 80% dead or dependent withoutspecific therapy


Hyperdense basilar artery

Vonofakos et al., AJNR 1983


Hyperdense basilar artery

95 patients with clinically suspected vertebro-basilar ischemia

Sensitivity 71,4%Specificity 97,5%

Goldmakher et al., Stroke 2009 www.uniklinikum-dresden.de

CT angiography - BAO

Lev et al., J Comp Assist Tomogr 2001; Bash et al., AJNR 2005; Nguyen-Huynh et al., Stroke 2008


TOF-MRA – Intracranial occlusion

Bash et al., AJNR 2005

(numbers in parenthesis corrected for DSA false-positive occlusion)

Stenoses, slow flow


posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS)

pc-ASPECTS 10 = no early ischemic changes

pc-ASPECTS 0 = ischemic changes in all posterior circlation territories

Puetz et al., Stroke 2008

pc-ASPECTS

NCCT - 9

CTA-SI - 6

Follow-up - 5

LPCA

Pons

Lcereb

LPCA

Pons

Lcereb

LThal

LPCA


CTA-SI – increased sensitivity

Patients with clinically suspected vertebrobasilarischemia

Puetz et al., Stroke 2008


BAO - pc-ASPECTS predicts outcome

Patients with BAO <48h (n=184)

Recanalization (TIMI 2-3; n=99)mRS 0-250%

6%

Strbian et al., Ann Neurol 2013

mRS 0-238%

4%


CTP – Increased sensitivity posterior circ.

van der Hoeven et al., Stroke 2015


CBV lesion extent predicts outcome in BAO

CBV-pc-ASPECTS <8: poor outcome (mRS 4-6): OR = 9.3 (95%CI 2.2-41)

Alemseged et al., Int J Stroke 2017; Pallesen et al., J Neuroimaging 2015 www.uniklinikum-dresden.deOppenheim et al., AJNR 2000

31% of posterior circulation strokes DWI negativ < 24 hours

posterior circ.

anterior circ.

24h

DWI in posterior circulation stroke

7 ho

urs

48 h

ours


pc-ASPECTS = 10-2-2 = 6

N=50 (1998 – 2010)- 82% i.v./i.a. recanalizing therapies- 24% good Outcome (mRS 0-2)

pc-ASPECTS >8 independent predictor forgood Outcome (OR 3.9, CI95% 1.4-11.7)

pc-ASPECTS <8PPV for poor Outcome 94%

Nagel et al., Int J Stroke 2011

pc-ASPECTS on DWI predicts outcome


I pc-ASPECTS (CTA-SI)Stroke 2008; n=46

I Pons-midbrain index (CTA-SI)Stroke 2008; n=16

I Renard-Score (DWI) AJNR 2008; n=16

I Brainstem DWI Score (DWI)AJNR 2009; n=29

I Bern DWI Score (DWI)CVD 2011; n=36

Posterior Circulation Imaging scores

combination 3. und 4.


I Posterior circulation collateral score (pc-CS)van der Hoeven et al., Int J Stroke 2017

I BATMAN score Alemseged et al., Stroke 2017

Posterior Circulation collateral scores

0-3, 3-5, 6-10

0-6, 7-10

Treatment (thrombolysis, EVT) Is BAO different from AAO?

Less thrombolysis bleeding in BAOHigher recanalization with IVTEndovasc. access: technically more difficult (?) longerdelays (?)

Bleeding: Sarikaya Stroke 2011; Time to TTT: Greving Neurology 2012; Recanalisation: Vergouwen/BASICS Stroke 2012

Schonewille Lancet Neurol 2009; Mattle Lancet Neurol 2011

Similar recanalisation ratesTime is brainSmall brainstem core = better prognosis (?)If recanalisation = betterprognosis

Different Similar

(courtesy Patrik Michel)


BAO: Recanalization improves outcome

Kumar, Shahripour, Alexandrov. J NeuroInterv Surg 2015

0.67 (0.63-0.72)www.uniklinikum-dresden.de24

IV-thrombolysis - Recanalization

Strbian et al. Stroke 2014; Riedel et al., Stroke 2011

>8mm

Riedel (MCA)


IV-thrombolysis - Recanalization

i.v.-thrombolysis


EVT – recanalization rate and good outcome

Recanalization Good outcome (mRS 0-2)

80.0% (70.7%-88.0%) 42.8% (34.0%-51.8%)

Phan et al. J NeuroInterv Surg 2015


IAT not associated with improved outcomein the BASICS Registry (n=592)

Schonewille et al, Lancet Neurology 2009

Mild-moderate deficit

Severe deficit

1.49 (1.00–2.23)

1.06 (0.91–1.22)

(adjusted for age, NIHSS, time to treatment, prior stroke, location occlusion, diabetes)


BEST: terminated early (presented WSC 2018)BASICS: recruitingBAOCHE: recruiting

Kaiser, Gerber, Puetz. Neuroradiologie Scan 2018

EVT trial results (26.04.2019)


ESO-guidlines, AHA guidlines

Turc et al.. Eur Stroke Journal 2019; Powers et al., Stroke 2018 www.uniklinikum-dresden.de30

BEST trial – study design

Liu et al.. Int J Stroke 2017; Liu et al., WSC 2018 (abstract)

April 2015 to September 2017Terminated early after 131/344 patients (DSMB)

- Exessive crossovers (21.5% medical EVT)- Drop in recruitment


BEST trial – Results (WSC 2018)

Liu et al.. WSC 2018

Intention to treat

Per protocol

As treated

BASICS-Trial

www.basicstrial.com van der Hoeven et al., Trials 2013

n=252 (target: 282)

< 6 hours since estimated time of BAO


Futile recanalization

Hussein and Qureshi, J Neuroimaging 2011

„Futile recanalization“www.uniklinikum-dresden.de

Futile recanalization

Irreversibly injured tissue („core“)

Complications of therapy

Time-window


Futile recanalization – infarct core

Lindsberg et al., Eur Stroke Journal 2016

pc-ASPECTS > 8: 30% futile recanalization

pc-ASPECTS < 8: 80% futile recanalization


Time is brainstem in basilar artery occlusionBASICS registry

Poor Outcome Adjust. RR

62% -

67% 1.06(0.91-1.25)

77% 1.26 (1.06-1.51)

85% 1.47 (1.26-1.72)

Mervyn et al., Stroke 2012; Mokin et al., Stroke 2016


Time is brainstem in basilar artery occlusion……but not if pc-ASPECTS > 8 (minor ischemic changes)

Strbian et al., Ann Neurol 2012

pc-ASPECTS > 8: Onset-to-treatment time (< 48h) not associated with clinical outcome

pc-A

SPEC

TS 8

-10


Time is brainstem in basilar artery occlusion……but not if favourable BATMAN score (good collaterals)

Alemseged et al., Stroke in press

BATMAN Score 7-10: Onset-to-treatment time (<6h versus >6h) not associated with clinical outcome

0-6, 7-10


IClinical presentation

IDiagnosis

I Imaging scores

I TreatmentIVT vs. EVTTimeTechnical aspects

39

Outline

…remember:I‘m a stroke neurologist.


I 69 y/0 female

I lsn day before

I Found with left hemiplegia, dysarthria, nystagmus, hemianopsia, anicocoria

I NIHSS 18

40

Example: Technical difficulties

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Angioplasty20:15

41

1. retriever 2. Retriever+ aspiration

19:23

4x30 Enterprise Stent20:00

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2.5x9 Coroflex Stent

Angioplasty

21:25

41414141

Stent

Final result

16:55Start EVT

Technical difficultiesFinFinnal al resresesultultultt

21:35

Final resulttirofiban

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Technical difficulties - F/U MRI


a. Cardioembolic

b. Embolism from tandem vertebral artery steno-occlusion

c. In Situ atherosclerotic thrombosis

Baik et al., Radiology 2019

a b c

EVT success associated with etiology

www.uniklinikum-dresden.deBaik et al., Radiology 2019

EVT success associated with etiology


ADAPT versus Stent-retriever

Gerber et al., Neuroradiology 2017; Alemseged et al., BATMAN collaboration: ESOC 2019 www.uniklinikum-dresden.de

I Variable clinical symptoms, frequently stuttering courseDo not forget to consider

I Imaging scores predict outcome and treatment response (late timewindow)

I I.v.-thrombolysis with higher recanalization-rates compared to Anterior Circ.

I EVT with similar recanalization rates compared to Anterior Circulation, butPost. Circ. is different: heterogeneous vessel pathologiesEtiology of BAO may effect outcome

I Benefit from EVT very likely – but not scientifically proven (BASICS)

46

Summary

Fig.: Die Anatomie des Dr. Tulp; www.wikipedia.org

… and Stroke Network partners

Acknowledgement

Stroke Team …Thank you!

[email protected]

europeancourseininterventional i neuroradiology i ... in post circ stroke...ivisual fielddefects...

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