neurointerventional treatment of acute stroke in 2015 at abbott northwestern hospital
TRANSCRIPT
![Page 1: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/1.jpg)
Neurointerventional Treatment of Acute Stroke in 2015 at
ANW
Yasha Kayan, MDJosser E. Delgado, MD
Abbott Northwestern HospitalInnovation Summit 2015
![Page 2: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/2.jpg)
2
Acute Ischemic Stroke Treatment
Ischemic Stroke
IV-tPA
IA~21%
~6%
• IV-tPA– large & small vessel
occlusions – Within 4.5 hours from
onset
• Intra-arterial– Mechanical
Thrombectomy & IA-tPA– IV-tPA candidates &
non-candidates– large vessel occlusions
![Page 3: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/3.jpg)
33
Hyper-dense Clot Sign
Hyperdense MCA Clot
![Page 4: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/4.jpg)
44
>8mm = 0% recanalization
Riedel et al. Stroke 2011,42:1775-1777
Large Clot Size Decreases Probability of Recanalization from IV-tPA
Why is IV-tPA not enough?
Clot Length (mm)
Prob
abili
ty o
f Rec
anal
izatio
n
![Page 5: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/5.jpg)
5
Acute Ischemic Stroke: ELVOs
• Acute ischemic stroke from an emergent large vessel occlusion (ELVO) is a major medical emergency that could lead to death or significant disability among survivors if untreated
![Page 6: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/6.jpg)
66
Large Vessels of the Brain
• Main Vessels Treated with Thrombectomy – MCA – M1
& M2– ACA (A1)– ICA– Basilar– PCA
M1
M2
ICA
Basilar
A1PCA
![Page 7: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/7.jpg)
7
Thrombectomy Locations
MCA
ICA
Posterior
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
M1
ICA Terminus
Basilar
M2
PCA
M3
ANW thrombectomy locations 2012-July2015 N=126
![Page 8: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/8.jpg)
88
Symptoms of Large Vessel Occlusions
Peter Vanacker, Mohamed Faouzi, Ashraf Eskandari, et al. EJMINT Original Article, 2014: 1444000227 (30th October 2014)
![Page 9: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/9.jpg)
9
Cortical Signs
RIGHT BRAIN: LEFT BRAIN:
- Right gaze preference - Left gaze preference
- Neglect - Aphasia
• If present, think LARGE VESSEL stroke
![Page 10: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/10.jpg)
1010
Neuro IR Angio Suite
![Page 11: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/11.jpg)
1111
Thrombectomy Arterial Access
![Page 12: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/12.jpg)
12
Mechanical ThrombectomyProcedural Overview
Device Selection and Preparation:
Wire and catheter passed from femoral artery, over the aortic arch, through the internal carotid artery, to the middle cerebral artery (MCA) and through the clot.
(Clot in MCA in illustration)
![Page 13: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/13.jpg)
13
Mechanical ThrombectomyProcedural Overview
Positioning and Deployment of stent in the clot:Guide catheter removed and stent catheter
advanced over the wire through the clot.
![Page 14: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/14.jpg)
14
Mechanical ThrombectomyProcedural Overview
Positioning and Deployment of stent in the clot:
Catheter pulled back, stent deployed into clot.
![Page 15: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/15.jpg)
15
Mechanical ThrombectomyProcedural Overview
Deployment of stent in the clot:Stent embedded in clot –
traps the clot within device mesh.
![Page 16: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/16.jpg)
16
Mechanical ThrombectomyProcedural Overview
Stent and clot removal:Stent with embedded clot pulled back into guide catheter.
Entire system removed from femoral artery.View of clot after retrieval:
![Page 17: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/17.jpg)
1717
Penumbra Device (ADAPT Technique)
Direct Aspiration by large catheter at the site of thrombus
Rapid and Painless Clot Extraction
Intact Clot Extraction may reduce distal emboli
Spiotta, et al. JNIS, 1/14
![Page 18: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/18.jpg)
1818
“Solumbra” Aspiration + Stent-Retriever Technique for Thrombectomy
![Page 19: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/19.jpg)
19
Evidence for Mechanical Thrombectomy in 2013
• 3 randomized trials comparing IV-tPA to intra-arterial therapy published in NEJM in 2013 found no difference in clinical outcomes:
IMS III SYNTHESIS EXPANSION MR RESCUE
![Page 20: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/20.jpg)
20
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI
LVO (ICA, M1): 33% 34% 81%Successful
recanalization(TICI 2b/3):
44% Not reported 27%
Good clinical outcome (mRS 0-2): 43% 42% 13%
Symptomatic ICH: 6% 6% 5%
Death (90 days): 19% 8% 19%
Evidence for Mechanical Thrombectomy in 2013
![Page 21: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/21.jpg)
21
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI
LVO (ICA, M1): 33% 34% 81%Successful
recanalization(TICI 2b/3):
44% Not reported 27%
Good clinical outcome (mRS 0-2): 43% 42% 13%
Symptomatic ICH: 6% 6% 5%
Death (90 days): 19% 8% 19%
Evidence for Mechanical Thrombectomy in 2013
Outdatedtechnology
![Page 22: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/22.jpg)
22
Thrombectomy Devices
2004 2007 2010
MERCI
Penumbra (original)
Solitaire
Trevo
2013
Penumbra5MAX ACE
2012 – “stent-retrievers”
2013 – large bore
aspiration
![Page 23: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/23.jpg)
23
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI
LVO (ICA, M1): 33% 34% 81%Successful
recanalization(TICI 2b/3):
44% Not reported 27%
Good clinical outcome (mRS 0-2): 43% 42% 13%
Symptomatic ICH: 6% 6% 5%
Death (90 days): 19% 8% 19%
Evidence for Mechanical Thrombectomy in 2013
Most ptsDID NOT HAVE
large vesselocclusions
![Page 24: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/24.jpg)
24
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI
LVO (ICA, M1): 33% 34% 81%Successful
recanalization(TICI 2b/3):
44% Not reported 27%
Good clinical outcome (mRS 0-2): 43% 42% 13%
Symptomatic ICH: 6% 6% 5%
Death (90 days): 19% 8% 19%
Evidence for Mechanical Thrombectomy in 2013
Successfulrecanalization
ratesWERE LOW
![Page 25: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/25.jpg)
25
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI
LVO (ICA, M1): 33% 34% 81%Successful
recanalization(TICI 2b/3):
44% Not reported 27%
Good clinical outcome (mRS 0-2): 43% 42% 13%
Symptomatic ICH: 6% 6% 5%
Death (90 days): 19% 8% 19%
Evidence for Mechanical Thrombectomy in 2013
But also… no differencein risk profile
compared to iv-tPA
![Page 26: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/26.jpg)
26
• Recent advances in endovascular thrombectomy devices have led to – higher rates of successful recanalization– marked reduction in thrombectomy procedures
times
Translates into improved clinical outcomes
Recent Advances in Treatment
![Page 27: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/27.jpg)
27
MR CLEAN Trial - 2015
![Page 28: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/28.jpg)
28
MR CLEAN: What Was Different?
• Confirmation of large vessel occlusion (ELVO) was required– ELVOs confirmed by CTA– Imaging confirmation was not required in IMS3
• Specific measures taken to minimize selection bias– 100% of interventional stroke centers in Netherlands
participated
• Majority of procedures with modern technology
![Page 29: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/29.jpg)
29
MR CLEAN Trial Design
• Prospective RCT comparing Best Medical Management vs Best Medical Management + IA therapy
• Key inclusion criteria
– Anterior circulation ELVO confirmed by CTA– IA treatment initiated within 6 hours from
onset• Primary Outcome: mRS score at 90 days (blinded assessment)
![Page 30: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/30.jpg)
30
Intervention Improves Outcomes
MR CLEAN Results
![Page 31: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/31.jpg)
31
acOR 2.16 (95% CI: 1.39 to 3.38)acOR > 1 indicates higher odds of acheiving functional independence in favor of intervention
Intervention Control0%
10%
20%
30%
40%32.6%
19.1%
mRS ≤ 2 at 90 Days
Intervention Improves Outcomes
MR CLEAN Results
![Page 32: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/32.jpg)
32
Intervention Control
Mortality within 7 days 11.6% 12.4%
Mortality within 30 days 18.9% 18.4%
Symptomatic ICH 7.8% 6.4%
“There was no difference in the occurrence of serious adverse events between the groups during the 90 day
follow-up. (p=0.31)”
MR CLEAN Investigators, A Randomized Trial of Intra-Arterial Treatment for Acute Ischemic Stroke, NEJM 2014
Intervention Is Safe
MR CLEAN Results
![Page 33: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/33.jpg)
33
Intervention Benefits a
Broad Population
![Page 34: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/34.jpg)
34
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Primary Intervention: MERCI IA-tPA and clot
fragmentation... MERCI Stent-Trievers
LVO (ICA, M1): 33% 34% 81% 86%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33%Symptomatic
ICH: 6% 6% 5% 8%
Death (90 days): 19% 8% 19% 21%
Evidence for Mechanical Thrombectomy in 2015
![Page 35: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/35.jpg)
35
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Primary Intervention: MERCI IA-tPA and clot
fragmentation... MERCI Stent-Trievers
LVO (ICA, M1): 33% 34% 81% 86%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33%Symptomatic
ICH: 6% 6% 5% 8%
Death (90 days): 19% 8% 19% 21%
Evidence for Mechanical Thrombectomy in 2015
Moderntechnology
![Page 36: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/36.jpg)
36
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Primary Intervention: MERCI IA-tPA and clot
fragmentation... MERCI Stent-Trievers
LVO (ICA, M1): 33% 34% 81% 86%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33%Symptomatic
ICH: 6% 6% 5% 8%
Death (90 days): 19% 8% 19% 21%
Evidence for Mechanical Thrombectomy in 2015
Whenapplied
to ELVOs
![Page 37: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/37.jpg)
37
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Primary Intervention: MERCI IA-tPA and clot
fragmentation... MERCI Stent-Trievers
LVO (ICA, M1): 33% 34% 81% 86%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33%Symptomatic
ICH: 6% 6% 5% 8%
Death (90 days): 19% 8% 19% 21%
Evidence for Mechanical Thrombectomy in 2015
Leads tohigher
successfulrecanalization
rates
![Page 38: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/38.jpg)
38
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Primary Intervention: MERCI IA-tPA and clot
fragmentation... MERCI Stent-Trievers
LVO (ICA, M1): 33% 34% 81% 86%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33%Symptomatic
ICH: 6% 6% 5% 8%
Death (90 days): 19% 8% 19% 21%
Evidence for Mechanical Thrombectomy in 2015
With a lowrisk profile
![Page 39: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/39.jpg)
39
Evidence for Mechanical Thrombectomy in 2015
TICI 2b/3rate
mRS 0-2 at 90 days
Death rate
MR CLEAN 59% 32.6% v. 19.1% 21% v 22%
ESCAPE 72% 53% v. 29% 10% v. 19%
EXTEND-IA 86% 71% v. 40% 9% v. 20%
SWIFT PRIME 88% 60% v. 36% 9% v. 12%
REVASCAT 66% 44% v 28% 18% v 16%
5 Total Major Thrombectomy Trials Published in NEJM in 2015
![Page 40: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/40.jpg)
40
IV-tPA + Endovascular Treatment
In 2015:Now standard of care for
acute ischemic stroke due tolarge vessel occlusions
![Page 41: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/41.jpg)
41
Thrombectomy Patient Algorithm
ANW Thrombectomy Standardized Algorithm- Minimize risks• Thrombectomy is a high risk procedure- Maximize speed• Time is brain
![Page 42: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/42.jpg)
42
Thrombectomy Risk Considerations
Intra-Procedural Complications
![Page 43: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/43.jpg)
43
Thrombectomy Risk Considerations
Futile Recanalization
![Page 44: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/44.jpg)
44
Thrombectomy Risk Considerations
Post-Procedural Symptomatic Intracranial Hemorrhage
![Page 45: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/45.jpg)
45
Thrombectomy Patient Algorithm
5 Guiding Principles1. Always administer IV-tPA to ALL eligible patients2. Define stroke severity required to intervene3. Target proximal intracranial large-vessel
occlusions only: ICA terminus, M1, proximal M2, basilar
4. Simplify imaging used to assess infarct core5. Patient age and baseline condition matter
![Page 46: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/46.jpg)
46
ANW Mechanical ThrombectomyAnterior Circulation Strokes
Administer IV-tPA when appropriate
NIHSS ≥6 or global aphasia
Contact ANW Stroke Neurologist via OneCallNIR calculates NCCT ASPECTS*
ASPECTS ≥6 & Age ≤85
Not optimal candidate for
thrombectomy, may consider on an individual basis
LKW ≤6 hrs
No
Yes
LKW >6 hours or unknown
Transfer for emergent
thrombectomy
Obtain emergent CTA head / neck(on-site if possible)
NIR calculates CTA ASPECTS*CTA ASPECTS
≥6
CTA ASPECTS <6
*Imaging expires after 90 minutes
![Page 47: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/47.jpg)
Case Examples
![Page 48: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/48.jpg)
48
60 y/o man, driving
• Driving alone in car, wife following in another vehicle
• Suddenly unable to control right leg and right arm• Markedly accelerates, wife unable to keep up• Finally able to stop car, daughter and EMS note
unable to move right side or talk• Transferred via EMS to OSH• NIHSS = 23 at OSH prior to tPA
![Page 49: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/49.jpg)
49
![Page 50: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/50.jpg)
5050
The patient was taken to OSH and iv-tPA was administered. NCCT a favorable ASPECTS (10) with a hyperdense left MCA sign.
![Page 51: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/51.jpg)
51
Successful mechanical thrombectomy of an embolus to the M1 segment of the left middle cerebral artery with the 5 Max ACE aspiration catheter
![Page 52: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/52.jpg)
52
![Page 53: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/53.jpg)
53
• Regains ability to speak within an hour• First word was his wife’s name (she was thrilled!)• MRI shows area of ischemia in left corona radiata• Discharged to CKRI with minor coordination and
speech issues• CEA one week later and discharged to home with
minor deficits
Results
![Page 54: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/54.jpg)
54
Acute ischemia within the left corona radiata extending into the left basal ganglia.
![Page 55: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/55.jpg)
55
![Page 56: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/56.jpg)
56
47 y/o man, coughing
![Page 57: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/57.jpg)
57
![Page 58: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/58.jpg)
58
![Page 59: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/59.jpg)
59
![Page 60: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/60.jpg)
60
![Page 61: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/61.jpg)
61
![Page 62: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/62.jpg)
62
Abbott’s Thrombectomy Experience
– July 1st 2011 to December 31st, 2014107 mechanical thrombectomies (2-3 per month)– 49% women, 51% men– Mean age: 67.5 years (33 – 93 years)– Mean admission NIHSS: 16.5 (3 - 28)– History of atrial fibrillation: 43%– Mean distance from presenting ED to Abbott for
transfers: 51 miles (13 - 314 miles)
![Page 63: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/63.jpg)
63
Abbott’s Thrombectomy Experience
Successful recanalization (TICI 2b/3):86%
Mean time from symptom onset to reperfusion: 321 minutes
(5 hours 21 minutes)
![Page 64: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/64.jpg)
64
Abbott’s Thrombectomy Experience
• Intra-procedural complications: 6.5%– Embolus to previously-uninvolved vascular territory:
3.7% (ACA territory)– Vessel perforation: 1.9%– Catheter rupture/retention: 0.9%
![Page 65: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/65.jpg)
65
Abbott’s Thrombectomy Experience
– Symptomatic intracranial hemorrhage: 6.5%• SAH: 3.7%
– 75% received either IA-tPA or glycoprotein IIb/IIIa inhibitor intra-procedurally
• ICH: 2.8%– Futile recanalization: 4.7%
• Requiring hemicraniectomy: 2.8%• Resulting in death: 1.9%• 60% ICA terminus occlusions• 60% reperfused >5 hours from symptom onset
![Page 66: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/66.jpg)
66
Abbott’s Thrombectomy Experience
• Mean Neuro-ICU LOS: 3.5 days (0 – 19 days)• Mean hospital LOS: 6.9 days (1 – 22 days)• In-hospital mortality: 21.5%
![Page 67: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/67.jpg)
67
Abbott’s Thrombectomy Experience
• Discharge disposition:– Home: 23%– Rehabilitation facility: 38%– Skilled nursing facility: 16%– Expired/hospice: 23%
![Page 68: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/68.jpg)
68
Abbott’s Thrombectomy Experience
• Clinical outcome at 90-days available in 104 patients– 97%, 3 pts pending 90-day follow-up
![Page 69: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/69.jpg)
69
Abbott’s Thrombectomy Experience
All Patients:
TICI 0-2a(15%):
TICI 2b/3 (85%):
p-value:
mRS 0-2: 41% 6% 48% 0.002
mRS 3: 12% 12% 12% 1
mRS 4-6: 47% 81% 41% 0.05
8x
2x
![Page 70: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/70.jpg)
70
IMS III(N=629)
SYNTHESIS(N=362)
MR RESCUE(N=118)
MR CLEAN(N=500)
Abbott (N=119)
Primary Intervention: MERCI IA-tPA and clot
fragmentation MERCI Stent-Trievers ADAPT/ Solumbra
LVO (ICA, M1): 33% 34% 81% 86% 87%Successful
recanalization(TICI 2b/3):
44% Not reported 27% 59% 86%Good clinical
outcome (mRS 0-2):
43% 42% 13% 33% 44%
Symptomatic ICH: 6% 6% 5% 8% 8%
Death (90 days): 19% 8% 19% 21% 23%
Abbott’s Thrombectomy Experience
![Page 71: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/71.jpg)
71
2015
2014
2013
2012
0 50 100 150 200 250 300 350 400
180
154
151
176
28
74
106
122
43
52
56
64
Onset to ED Arrival ED Arrival to Arterial Puncture Arterial Puncture to Reperfusion
Standardizedalgorithm
implemented
Optimizing Delivery of Neurointerventional Stroke Care
![Page 72: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/72.jpg)
72
2014 20150%
5%
10%
15%20%
25%
30%
35%
40%
45%50%
MRS 0-2 Death
Optimizing Delivery of Neurointerventional Stroke Care
0
50
100
150
200
250
Door to Puncture Good Outcome
Mortality
Door to Puncture Time
![Page 73: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/73.jpg)
73
Conclusions
• Endovascular thrombectomy is a safe, highly effective procedure that saves lives and reduces disability when:
– Early treatment with IV-tPA for patients that qualify– Patients are carefully selected to identify proximal occlusions– Treatment is extremely fast
• For every four patients treated, one more patient is independent at long term follow up
![Page 74: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/74.jpg)
74
Conclusions
• Coordinated neurovascular team effort• Advent of new devices has led to
– decreased procedure times– high rates of successful recanalization– lower rates of intra-procedural complications
• Achieving TICI 2b/3 recanalization is requisite but does not guarantee a good clinical outcome
• Integrating systems of care & standardizing patient selection to decrease time to recanalization is imperative to maximize good clinical outcomes
![Page 75: Neurointerventional Treatment of Acute Stroke in 2015 at Abbott Northwestern Hospital](https://reader035.vdocuments.net/reader035/viewer/2022070602/587b3c3b1a28ab9c0e8b4cf5/html5/thumbnails/75.jpg)
75
Conclusions
• Each 5 minutes of delay eliminated benefit for one person out of every 100 treated with thrombectomy
• TIME IS BRAIN