Stroke EVTPanel discussion

26 female wake up stroke; NIHSS 22; R sided weakness and aphasia

Solitaire (ev3)- 2012, Trevo (Stryker), Revive™ SE (Codman), Etc…. etc…..

Stentretrievers - Stent or stent-like system for clot removal

ARTS (SOLUMBRA)(Aspiration-Retriever Technique for Stroke)

Techniques..

ADAPT…A Direct Aspiration First Pass technique

Techniques

A. Stent retriever B. Stent retriever with BCG C. Stent retriever with DAC (ARTS), SOLUMBRAD. ADAPT E. Other

Issues

• Trials• Simplicity• Change of techniques• Cost issues • One standard technique

P to P – 58 minutesPuncture to reperfusion – 18 minutes

F/U MRI; Some residual mild aphasia

Technique

• Simple – similar result in different hands and at all times

• Fast – stick to one technique • Each step as a protocol –

everybody in team in sync• Avoid experimentation in initial

phase • Other factors (selection, time

…) more important

Device – technique

Comparison of protocol- Randomised (Intervention Vs Standard medical therapy)

TREVO, Stryker Neurovascular

REVIVE, Codman Neurovascular

ERIC, Microvention

Technique ……

Choice of Stent retriever and why ?

A. Solitaire B. TrevoC. Revive D. ERICE. Other

14Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal

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SOLITAIRE 2 - IMPROVED TENSILE STRENGTH

Solitaire™ 2 Device

Solitaire™ FR Device

The Solitaire™ 2 Revascularization Device also employs a redesigned attachment zone offering a 2x improvement in joint strength designed to eliminate unintended detachments

Peak Load0

2

4

6

8

10

12

14

Solitaire™ FR DeviceSolitaire™ 2 Device

(N)

15Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal

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SOLITAIRE 2 Device overviewReference Number

Recommended Vessel

Diameter (mm)

(A) Total Length (mm)

(B) Retrieval Zone (mm)

(C) Device Diameter

(mm)

(D) Push Wire Length (cm)

(E) Distal Markers

(F) Proximal Markers

Distance from Distal Tip to Flourosafe

Marker (cm)

Micro Catheter ID

(in)

SFR2-4-15 2.0 - 4.0 26 15 4 180 3 1 <130 .021

SFR2-4-20 2.0 - 4.0 31 20 4 180 3 1 <130 .021

SFR2-4-40 2.0 - 4.0 50 40 4 180 3 1 <130 .021

SFR2-6-20 3.0 - 5.5 31 20 6 180 4 1 <130 .027

SFR2-6-30 3.0 - 5.5 42 30 6 180 4 1 <130 .027

Trevo and Trevo XP

High Integration

Radial Force

Large Cell Size with

Low Coverage

Tubular Design

INTEGRATE & PULLPhotograph taken by Stryker Neurovascular.

Solitaire™ FR Device vs. Trevo™* DeviceDesign Overview

**Competitive Testing Report FD2815.***Covidien Testing Data: FD2601A

Trevo™* Device

Solitaire™ DeviceImages property of Covidien. Image is an artistic rendering

and not a n exact depiction of the Solitaire™ FR Device.Image property of Covidien. Image is an artistic

rendering and not a n exact depiction of the Trevo™ Device.

• The Solitaire™ FR device - Parametric™ design that may provide multiple planes of clot contact. •Trevo - straight cut tube ; struts of the Trevo™* device to cut into the clot

Consistent Cell Size

Variable Cell Size

Force-Flex™

Straight-Cut

64 year old man with left hemiparesis, bought to emergency in 60 min, NIHSS 16

No improvement after IV tpa

54, M, 2 hours, NIHSS - 17

Tandem – Proximal ICA occlusion (AS) with MCA clot

A. Distal followed by proximal PTA/StentB. Proximal PTA followed by distal C. Proximal stent followed by distal D. Proximal suction followed by distalE. Distal with no proximal intervention

Follow up

Patient ImprovedmRs 2 at discharge

CTA 15 days later show occluded stent Right MCA opacifies through Acom

Anterograde vs retrograde approach:

Antegrade : Stenting first

Pros: Access to distal lesionPerfusion through collateral (in case of tandem MCA occlusion)Reduced risk of repeat embolism (??)

Cons: Delay in reperfusion of occluded territory

Retrograde: Thrombectomy first

Pros: Early reperfusion of occluded territoryCons: Access to distal lesion is limited

Risk of repeat embolism (??)

Our approach Acute stroke with ICA occlusion• Usually distal first , take the guiding catheter across

the stenosis• Terumo/microcatheter to cross• DAC/Neuron 6F - aspiration• Co-axial approach • Recanalize the I/C part• Check the proximal ICA (wire in situ)• If good flow , not a severe stenosis - wait• Usually needs Angioplasty/stenting• Drugs – If IV tPA given – Ecospirin 150 mg, Clopidogrel

225 mg ; other wise 300, 450 mg

• 28 patients• Antegrade approach (85.7%); Reverse approach (14.3%)• Antiplatelet: Load Aspirin (650 mg) when stenting anticipated. • Cone-beam CT after tt - No hmg, 600 mg loading dose of clopidogrel.

SICH in 2 (one received IV tPA)

• Retrospective; September 2010 and April 2013• Compared proximal vs distal approach • Weight-adapted bolus of tirofiban followed by a continuous infusion

for 24 h to prevent in-stent thrombosis• After exclusion of cerebral hemorrhage on follow-up imaging, 500

mg of acetylsalicylacid (ASA) and 300 mg of clopidogrel

Issues with Stenting in the acute setting: Factors to be considered.

• Infarct core volume

• Time to reperfusion

• Received IV tPA or not

• Antiplatelet to be tailored to above

• Need for Abciximab in case of in-stent thrombosis (increases bleeding risk)

• Risk of stent occlusion

• Antiplatelet protocol: Thrombolysis (Yes) – Ecosprin (300); CT Brain in 12 to 24 hours no hemorrhage add Clopidogrel.

• Thrombolysis (no) – Ecosprin 300 and Clopidogrel 600 loading

Emergency carotid stent – drug protocol

A. Loading with abciximab or equivalentB. Loading with aspirin and clopidogrelC. CT followed by loadingD. Single anti-platelet followed by second after a whileE. Other

• 60 years old female.• h/o hypertension and hypothyroidism• Acute onset left hemiparesis and left facial weakness• No history of LOC/seizures• CT Brain , perfusion and angio done 6 1/2 hours after ictus.

2 months later

A

D

A

C

B

A

E F

HG

A sixty five year old presented at five hours of symptom onset with a NIHSS of 22

Stenting

Still occluded

Patient presented with in 2 hours

Futile IV tpa

62/F, 3-hours, NIHSS 18

Imaging

A. CT, CTAB. CT, CTA, collateral scoringC. CT, CTA, CTPD. MR – DWI, MRAE. MR – DWI, MRP, MRAF. CT, CTA, MR- DWI

Patient presented with in 2 hours

Futile IV tpa

26 female wake up stroke; NIHSS 22; R sided weakness and aphasia

Good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203–5.099; P .014) was the independent predictor of good outcome amongst various collateral grading scales.

Arterial Collateral status – penumbra, retention of penumbra

Miteff system

A, Contrast opacification all sylvian branches. B, Some vessels can be seen at the Sylvian fissure. C, distal cortical filling alone

Modified Tan system. A, Less than 50% of the MCA territory. B, More than 50% of the MCA territory

Multiphase CTA

Better able to predict outcomes than single phase and perfusion CT

CT, CTA, CTP….CT perfusion imaging

MTTCBF CBVQuantitative 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.

CT perfusion•

J Neurol Neurosurg Psychiatry. 2013 Jan 25. CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke.

CTP was more frequently diagnostic than NCCT (80% vs 50%, p<0.001). Normal CTP in 86/87 patients with stroke mimics supported withholding tPA

Consideration of multiple available CT sequences increases confidence for correct stroke diagnosis among inexperienced readers and may facilitate identification of stroke mimics

Stroke. 2013 Feb 12. [Epub ahead of print]Computed Tomography Workup of Patients Suspected of Acute Ischemic Stroke: Perfusion Computed Tomography Adds Value Compared With Clinical Evaluation, Noncontrast Computed Tomography, and Computed Tomography Angiogram in Terms of Predicting Outcome.Zhu G, Michel P, Aghaebrahim A, Patrie JT, Xin W, Eskandari A, Zhang W, Wintermark M.

J Neurointerv Surg. 2012 Nov 26. [Epub ahead of print]CT perfusion-guided patient selection for endovascular recanalization in acute ischemic stroke: a multicenter study

Beating the Bullet!!!!

•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.

30-min delay in angiographic reperfusion reduced the relative likelihood of a good clinical outcome by 12% i adjusted analysis.

What did ESCAPE trial aim for?P2P- picture to puncture

P2R – picture to recanalization

A. P2P - 90 min, P2R - 120 minB. P2P - 60 min, P2R – 120 minC. P2P - 60 min, P2R – 90 minD. P2P – 45 min, P2R – 60 minE. P2P – 30 min, P2R – 60 min

TIME for recanalization• Onset to door time

• Door to Imaging/picture

• Picture to puncture (P2P)

• Puncture to recanalization time

Hospital processes

Technical skills

• Onset to puncture/groin time

• Onset to recanalization time

• Door to Puncture (D2P)

• Picture to recanalization (P2R)

Society infrastructure

Ultimate predictor

One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed.

The worst clinical outcomes were noted with door-to-puncture times of 136 minutes or greater

( J Am Heart Assoc. 2014;3:e000859

N=478

P2P Challenges

• CT vs MRI

• Availability of the angiosuite SOS

• 24x 7 neurointerventionist, anaesthetist, technician, nurse

• Team of like minded people

• Overcoming the Financial Barrier

Rapid Triage Protocol and Stroke Team Notification

Single Call Activation System

Changes at Medanta

Door time recording by CCTV footage

Transfer Directly to CT

Rapid Acquisition and Interpretation of Brain Imaging

Multimodal imaging protocol (CTA/CTP)

Parallel approachClinical assessment ‘en route’ to Imaging.Access line and blood investigations (POC)Prepare IV tPAAlert Angio suite/ Lab personnel Financial considerations/ undertakingConsent – pre written

Changes at Medanta

Puncture to Recanlization time

• Planning on CT angiography

• Local anaesthesia

• No groin preparation

• Putting Foley’s after deploying stent

• Standardized stroke kit that is ready to go

(Stroke. 2014;45:e252-e256.)

Tips to getting the clot on first pass

• Use of balloon guide catheter

• Long stent 4mm X 40 mm solitaire

• Push & Fluff technique

• Prayer!!!

• 41 year old male, Severe MR, EF 20%• Stroke in sleep, NIHSS 14 on admission

6:22AM

Patient made gradual recoveryLeft LL 4/5 and UL 3/5 - 30 day follow upmRS at 90 days- 0

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Dr Vipul Gupta

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