Post on 15-Mar-2021
transcript
Mechanical Thrombectomy in Acute Ischemic Stroke
Michel Elias Mawad, M.D.
Neurological Institute
TIMELY ANTEGRADE REPERFUSION
< 6 HOURS
PHARMACOLOGICAL
IV. r-TPA
MECHANICAL
THROMBECTOMY THROMBO- ASPIRATION
Have several advantages over pharmacologic thrombolysis and may be used as primary or adjunctive strategies.
• Provide faster recanalization.
• Lessen and may even preclude the use of chemical thrombolytics, in this manner very likely reducing the risk of ICH.
• Possible to extend the treatment window beyond the limit of 6–8 hours (T occlusion of ICA or basilar artery thrombosis).
• More efficient at coping with material resistant to enzymatic
degradation (white organized clots in atrial fibrillation).
• Fragmenting a clot increases the surface area accessible to fibrinolytic agents and allows inflow of fresh plasminogen, which, in turn, may increase the speed of thrombolysis.
MECHANICAL REVASCULARZATION PROCEDURES
1) Mechanical thromboaspiration 2) Mechanical Thrombectomy
SUCTION THROMBECTOMY
SUCTION THROMBECTOMY
SUCTION THROMBECTOMY
SUCTION THROMBECTOMY
SUCTION THROMBECTOMY
MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY
Mechanical thrombectomy using
stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
Thrombectomy using stenttriever
MECHANICAL THROMBECTOMY
OUTCOME
• MANDATORY USE OF CTA/MRA FOR IDENTIFICATION OF PROXIMAL VESSEL
OCCLUSION
• USE OF LATEST GENERATION DEVICES (STENT TRIEVERS)
• OUTCOME SIMILAR IRRESPECTIVE OF GENDER
• OUTCOME SIMILAR IRRESPECTIVE OF AGE
• THROMBECTOMY WAS BENEFICIAL IN MORE PROXIMAL THEN DISTAL
OCCLUSION (ICA BIF. > M1 OCCLUSION > M 2 OCCLUSION)
• THROMBECTOMY WAS BENEFICIAL DESPITE EXTRACRANIAL ICA
OCCLUSION
• THROMBECTOMY WAS BENEFICIAL WITH OR WITHOUT IV r-TPA
Mechanical Thrombectomy in Acute Stroke
1
hr
2
hr 3
hr
4
hr
5
hr
6
hr
IV r-TPA GROIN
PUNCTURE
STENT TRIEVER
DEPLOYMENT ONSET OF
SYMPTOMS
1 2 3 4 5 6 7 8 9 1
0
11 1
2
ONSET OF
SYMPTOMS
HOURS
TIME WINDOW FOR GROIN PUNCTURE / CLOT ACCESS
Mechanical Thrombectomy in Acute Stroke
TRIAL MR
CLEAN
ESCAPE EXTEND IA SWIFT
PRIME
REVASCAT
TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.
ASPECTS 9 9 NR 9 7-8
IV TPA 87% 73% 100% 100% 68%
TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’
STENTTRIEVER 81% 86% 100% 100% 100%
MRS 0-2
ABS.
IMPROVMT.
32.6%
13.5%*
53%
23.7%*
71.4%
31.4%*
60%
24.7%*
15.5%*
TICI 2b/3 58% 72% 86% 88% 65%
EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE
NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17
SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%
Mechanical Thrombectomy in Acute Stroke
TRIAL MR
CLEAN
ESCAPE EXTEND IA SWIFT
PRIME
REVASCAT
TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.
ASPECTS 9 9 NR 9 7-8
IV TPA 87% 73% 100% 100% 68%
TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’
STENTTRIEVER 81% 86% 100% 100% 100%
MRS 0-2
ABS.
IMPROVMT.
32.6%
13.5%*
53%
23.7%*
71.4%
31.4%*
60%
24.7%*
15.5%*
TICI 2b/3 58% 72% 86% 88% 65%
EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE
NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17
SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%
Mechanical Thrombectomy in Acute Stroke
TRIAL MR
CLEAN
ESCAPE EXTEND IA SWIFT
PRIME
REVASCAT
TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.
ASPECTS 9 9 NR 9 7-8
IV TPA 87% 73% 100% 100% 68%
TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’
STENTTRIEVER 81% 86% 100% 100% 100%
MRS 0-2
ABS.
IMPROVMT.
32.6%
13.5%*
53%
23.7%*
71.4%
31.4%*
60%
24.7%*
15.5%*
TICI 2b/3 58% 72% 86% 88% 65%
EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE
NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17
SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%
Mechanical Thrombectomy in Acute Stroke
TRIAL MR
CLEAN
ESCAPE EXTEND IA SWIFT
PRIME
REVASCAT
TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.
ASPECTS 9 9 NR 9 7-8
IV TPA 87% 73% 100% 100% 68%
TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’
STENTTRIEVER 81% 86% 100% 100% 100%
MRS 0-2
ABS.
IMPROVMT.
32.6%
13.5%*
53%
23.7%*
71.4%
31.4%*
60%
24.7%*
15.5%*
TICI 2b/3 58% 72% 86% 88% 65%
EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE
NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17
SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%
Mechanical Thrombectomy in Acute Stroke
TRIAL MR
CLEAN
ESCAPE EXTEND IA SWIFT
PRIME
REVASCAT
TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.
ASPECTS 9 9 NR 9 7-8
IV TPA 87% 73% 100% 100% 68%
TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’
STENTTRIEVER 81% 86% 100% 100% 100%
MRS 0-2
ABS.
IMPROVMT.
32.6%
13.5%*
53%
23.7%*
71.4%
31.4%*
60%
24.7%*
15.5%*
TICI 2b/3 58% 72% 86% 88% 65%
EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE
NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17
SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%
Mechanical Thrombectomy in Acute Stroke
12:OO NOON 3:00 PM 6:00 PM
MECHANICAL THROMBECTOMY
In Summary,
• Use IV r-TPA in all eligible
patients
• Avoid large volume infarcts
• Obtain CT & CTA to exclude
hemorrhage and to identify
large vessel occlusion
• Initiate Mechanical
Thrombectomy early, ideally
within 4 hours from onset of
symptoms
• Mandatory use of latest
generation devices
• Refer NIHSS > 10 to
Comprehensive Stroke Center
1. Give aspirin
2. Give heparin
3. Give tPA
4. Give tPA AND proceed to endovascular
treatment
5. Do not give tPA BUT proceed to endovascular
treatment
What is your Management Plan?
Emergency cerebral arteriogram
Emergency cerebral arteriogram
MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY