Interventions in acute ischaemic stroke –Where do we stand in 2014?

Vipul GuptaNeurointerventional Surgery

(Interventional Neuroradiology)Institute of Neurosciences

Medanta the Medicity

Intervention in Stroke - 2014

• Rationale

• Good outcome – what have we learned

• Current technique - 2014

• Future evolution

• Data, trials – past and on-going

Issues with IV tPA

• Time factor

• Large vessel disease

• Time to recanalize

• C.I. – anti-coagulants, recent surgery, wake-up strokes….

Less than 10% patients are eligible

•Distal MCA – 44%

•Proximal MCA - 30%

•Terminal ICA - 6%

•Tandem cervical ICA/MCA -27%

•Basilar artery- 30%

Prerecombinant tissue plasminogen activator, National Institutes of

Health Stroke Scale score, systolic blood pressure, glucose, and

Thrombolysis in Brain Ischemia flow grade at the occlusion site were

the negative independent predictors for complete recanalization in the

final model.

• 53 studies, 2066 patients

• Sp.- 24%, IV tPA- 46%, IA- 64%, Mechanical- 84%

• Good outcome more in recanalized patients (OR- 4.4)

• Less mortality in recanalized patients

•The Interventional

Management of Stroke

pilot trials tested

combined IV/IA therapy

onset.

•Among the 54

cases, only time to

angiographic reperfusion

and age independently

predicted good clinical

outcome after

angiographic

reperfusion.

Intra-arterial recanalization

• Major vessel occlusion- IV-tPA given- but not effective- bridging

• IV-tPA not possible-( >4.5 hrs, wake-up strokes, anti-coagulants, recent surgery etc. ) (and MVO)

Good outcome in IAT - 2014

• Viable tissue – Penumbra

• TICI IIb/IIIa

• Time…time…time

Expertise, team, system…

Imaging approaches for case selection

• NCCT (ASPECTS)- NIHSS

• NCCT & CTA, CTA-SI

• NCCT, CTA & CTP

• MRI-DWI, (MRA, PWI)

What information is needed?

• Bleed

• Infarct core – is critical 70-100 ml

• Major vessel occlusion

• Tissue at risk- penumbra

Time, imaging interpretation, unstable patients

• Hemorrhage

# NCCT- excluding hemorrhage is necessary and sufficient for IV –tPA

# MR- quite good, expert interpretation

• Major vessel occlusion

# CTA better & quicker than MRA for MVO

# Can be obtained without slowing IV thrombolysis.

• Core

# Most accurate - DWI.

# NCCT – least

# CT A- SI- better than NCCT

# CT perfusion- CBF, CBV, MTT – better

Imaging…

Concept of Penumbra

CBF/MTT CBVMatched

No penumbra

CBF/MTTCBV

penumbra

Penumbra# MVO with small core (CTA-SI or DWI)-

penumbra is usually there

# CT perfusion

CT, CTA, CTP….

CT perfusion imaging

MTTCBF CBV

Quantitative CTP mismatch classification using relCBF and Tmax is similar to perfusion-diffusion MRI.

Stroke. 2012 Oct;43(10):2648-53. Epub 2012 Aug 2.

Incremental improvement in interobserver reliability was demonstrated

for NCCT, CTA-SI, and CTP-CBV, respectively. (Stroke. 2013;44(1):234-6) 25.

5:18 am

5:23AM

CBV-

CORE

CBF, MTT-

perfusion

Patient presented with in 2 hours

Futile IV tpa

NCCT & NIHSS…

Not

reliable

NCCT & CTA, CTA-SI….

Can be implemented everywhere, good enough in expert hands

DWI MTT

Pre tPA

Post tPA

MRA

MRI guided intervention? MRI

Great for core, time??

Issues• Criteria for penumbra

• DEFUSE – PWI 120% of DWI

• DEFUSE 2 – 1.8

• MR RESCUE - DWI 70% or less

PENUMBRAMERCI

STENTREIVERS- SOLITAIRE, TREVO…..

Technique

120

64.6 54.7

0

50

100

150

MS PS RS

TIME

MS

PS

RS

59.186.6 93

0

50

100

MS PS RS

Recanalization

MSPSRS

31.5 36.646.9

0

20

40

60

MS PS RS

MRS<=2

MS

PS

RS

MERCI

PENUMBRA

SOLITAIRE

AJNR, Jan, 2013

•68/M, Acute onset right side weakness with aphasia.

IV- tPA given, no improvement

Clinical …• Left hemiplegia, left UL and LL 0/5

• Left facial palsy

• Dysarthria

• Confusion

• NIHSS 14 on admission5:14AM

• 60 years old female.

• h/o hypertension and hypothyroidism

• Acute onset left hemiparesis and left facial weakness

• CT Brain , CTP and CTA done 6 1/2 hours after ictus.

2 months later

Tight Stenosis Urgent stenting

Occluded brain

vessel

Opened up brain vessel

• 63 /M, AVR, Coumadin

• INR of 2.5

• RT hemiparesis - 2/5 in leg and 0/5 in arm

• Global aphasia

CBF CBV

Solitaire stent was deployed

Case 270 year old ladyHistory of sudden onset right UL and LL weakness of 2 hours duration, NIHSS 19

Left ICA occlusion Guiding

advancedLeft MCA occluded Good PCOM

Complete revascularisation

014 wire Tight stenosis AngioplastyFilter in place

Stenting Still occluded

Good collateral circulation through PCOM

Filter wire cut at

the groin

Follow up

Good clinical recovery

Came back 2 months later with wire point in the thigh

Removed after making an incision

• Entry criteria: age 22-85; NIHSS ≥8 and <30; ineligible or failed IV-tPA; accessible occlusion in M1 or M2 MCA/ICA/BA/VA; able to be treated within 8 h of onset

• Primary endpoint- TIMI- 2 or 3, no hmg;3 passes

• 113 patients

• Primary efficacy - Solitaire 61%vs MERCI 24%

• 3-month good outcome- Solitaire 58% /Merci 33%

• 141 patients, 6 experienced European centers.

• Median NIHSS- 18

• 74 patients received intravenous tPA

• Complete revascularization - 85%

• Good outcome - 55%

• Good outcome more frequent in pts with IV tPA 66% versus 42%

• Symptomatic ICH- 5 patients (4%)

Our results• Total No. of patients= 42 (M-19, F- 23)

• Time of arrival: 30 min- 840 min (mean 203.8 minutes)

• NIHSS at admission: 5-22 (Mean 14.33)

• MVO 39, IV tPA- 19

Good recanalization (TICI 2b or 3) in 57.1%

mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)

Recanalization V/s Outcome

Technical issues

• Recanalization rate - 60-90 %

• Calcified old clots

• MCA bifurcation/trifurcation clots

• I/C stenosis – more in Asian

• Balloon catheter – smaller tortuous arteries

• GA vs LA

• Proximal carotid stenosis /dissection

TREVO, Stryker Neurovascular

REVIVE, Codman

Neurovascular

ERIC, Microvention

Techniques..

• 6mm vs 4mm

•Length

•2 retriever

•ADAPT

•Proximal occlusion

and aspiration

•Distal aspiration

Intra-arterial methods

• IA-tPA- 71% (51)

• Microsonic – 71% SV Infusion with tPA (14)

• Merci- 73% (77)

• Penumbra- 85% (39)

• Solitaire- 75% (4)

Rapidity of treatment

• IMS 1 and II trials, 30-minute delay – 10%

less probability of independent existence

• Delay in IMS III was 32 min longer than

IMS I study

Case selection?

ISC 2013

Issues

• 21 sites- 8-years- 127 patients

• Revascularization in 67%, seventeen procedural complications

• Mostly used MERCI device- first generation;

• Trial completed over 8-years !!!

Time to groin puncture was 6 hrs 21 min !!!

Imaging to puncture- 2hrs 4min !!!

Trials…

• SWIFT PRIME (US)

• ESCAPE (Canadian)

• EXTEND- IA (Australia)

• POSITIVE trial (US)

• EASI trial (Canadian)

• EASY trial (France)

• PISTE (UK)

• SWISS (Swiss)

• RESILIENT (Brasil)

Where do we stand?

• Stent -retrievers – 80-90% recanalization (?70%)

• Time in < 1-hr

• Additional to t-PA

• Case selection (Penumbra imaging) & speed are crucial-“futile recanalizations”

• Further refinement of technique likely

• EXPERTISE, TEAM, SYSTEM….a challenge

• Results of randomized trials

• Need to do in monitored environment

Thank you