time for stroke thrombectomy… conference 2016...• thrombectomy plus usual care (thrombolysis) vs...
TRANSCRIPT
Time for Stroke Thrombectomy…
Jason Kendall Southmead Hospital
North Bristol NHS TrustSeptember 2016
• Technology• Evidence• Clinical cases• Referral guideline
Thrombectomy for acute ischaemic stroke
• Technology• Evidence• Clinical cases• Referral guideline
Thrombectomy for acute ischaemic stroke
“Do I need a thrombectomy…?”
The technology… how does it work?
Proximal occlusion… Recanalisation
What is the evidence?
• Thrombectomy plus usual care (thrombolysis) vs usual care alone • CTA confirmation of proximal arterial occlusion in anterior cerebral circulation
+ESCAPESWIFT-PRIMEREVASCATEXTEND-IA
All published in NEJM, 2015
TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
What is the evidence?
TRIALS outcome: pooled data (n=1287)
OR = 2.49 for reduced disability at 90 days
OR = 2.71 for functional independence (mRS = 0-2) at 90 days
NNT = 2.6 for reduced mRS by 1 point at 90 days
Effect consistent across wide range of age and stroke severity
Mean time to thrombolysis = 100 mins Mean time to thrombectomy = 285 mins The Lancet, April 2016
TRIALS key message• Thrombectomy (in addition to standard care) is effective
and safe
Translation into clinical practice• Who?• When? • Where?
Trial inclusion criteria and logistics…
Case 1• 40 year old male• Awoke at 0845am with RSW and speech
problems• Last seen well before bed at midnight • Wife called ambulance and taken to ED• Dysphasia with RSW• NIHSS 17
Case 1: CT on arrival 09:24
Case 1: CTA
Case 1 angio
RecanalisationMCA occlusion
Case 1 outcome• 24 hours NIHSS = 8 (17 at presentation)
• Home with ESD (after 2 weeks)• Walking• Moderate dysphasia
Case 1 Discussion pointsHow much damage is acceptable on CTH before procedure
futile?MR CLEAN vs ESCAPE, SWIFT PRIME, REVASCAT
How important is the onset time?REVASCAT (<8hrs), ESCAPE (<12hrs) vs others (<6 hrs)
Would CTP have been useful?SWIFT PRIME, ESCAPE, EXTEND-IA
Case 2• 90 year old female, previously living independently• Admitted with PE and new AF• Started rivaroxaban
• Dense left upper limb weakness and facial weakness whilst inpatient
• NIHSS 5
Case 2: CT 60 minutes from symptom onset
Case 2 CTA
…Discrepancy betweenNIHSS and proximal MCA
occlusion
Right MCA occlusion
Collateral flow from anterior cerebral artery…
Collateral flow from anterior cerebral artery…
Collateral flow from anterior cerebral artery…
Collateral flow from anterior cerebral artery…
Initial contrast image… …several seconds later
Recanalisation (120 mins post onset)Stent across thrombus
Case 2: outcome
• NIHSS 2 at 24 hrs, neurologically independent
• Discharged to residential home
Case 2 discussion pointsIs any age too old?
Inclusion criteria varied across trials16% > 80 years old in MR CLEAN
Is any NIHSS too low?Inclusion criteria varied across trialsOutcome for “minor stroke”?
Importance of CT angiography
Case 3• 79 year old female• Background hypertension• Presented one hour after symptom onset to
DGH• NIHSS 18• Dense right sided weakness and dysphasia
Case 3: initial CT at DGH
Case 3• CTA confirmed proximal MCA occlusion• Thrombolysis and transfer• Transfer from DGH to SMD took 2 hours• On arrival dypshasia and weakness improving• NIHSS 10• Taken straight to angio suite for intervention
Case 3 Angio
Recanalisation post iv tPAContinued to improve, discharged functionally independent NIHSS = 4
Case 3 discussion points• Right decisions with right information early
CT and CTA at referring centre? Repeat imaging if situation substantially changes during transfer
• How to achieve rapid transfer?Robust referral pathwayTreat inter-hospital transfer as 999 call Consider helicopter transfer
ED referral criteria for thrombectomy
Who? No upper age limitDemonstration of major vessel occlusion on CT angiogramNIHSS = 4 or higherTime from onset to intervention within 6 hours
When / Where? Monday – Friday, 8am – 4pm, Southmead Hospital
Action: (1) Commence IV thrombolysis (if no contra-indication)(2) Call stroke physician at Southmead to arrange transfer(3) Arrange transfer to Southmead ED
Conclusions
• Thrombectomy is effective and safe• CT and CTA essential for patient selection• Longer time window for thrombectomy compared
with thrombolysis• Urgent referral and rapid transfer
Time for Stroke Thrombectomy…
Jason Kendall Southmead Hospital
North Bristol NHS TrustSeptember 2016
Basilar artery occlusion
Basil Fawlty…?
Before… …after
National (IQR) NBT (IQR)
Onset to puncture (min) 211.5 (178.5-292.5) 168.5 (150-185)
Onset to end of procedure (min) 294.5 (234.5-360.5) 275 (216-285)
Puncture to deployment (min) 22 (15-31.5) 32 (20-35)
Puncture to end of procedure (min) 61.5 (41-85) 45 (31-108)
Clock start to puncture (min) 131.5 (89-181) 88.5 (65-92)
Clock start to deployment (min) 167.5 (111-208.5) 120 (112-124)
Clock start to end of procedure (min) 201.5 (152.5-254) 200 (120-200)
NBT experience30 cases from January – August 2016
SSNAP data:
National (IQR) NBT (IQR)
Onset to puncture (min) 211.5 (178.5-292.5) 168.5 (150-185)
Onset to end of procedure (min) 294.5 (234.5-360.5) 275 (216-285)
Puncture to deployment (min) 22 (15-31.5) 32 (20-35)
Puncture to end of procedure (min) 61.5 (41-85) 45 (31-108)
Clock start to puncture (min) 131.5 (89-181) 88.5 (65-92)
Clock start to deployment (min) 167.5 (111-208.5) 120 (112-124)
Clock start to end of procedure (min) 201.5 (152.5-254) 200 (120-200)
NBT experience30 cases from January – August 2016
SSNAP data: