Thombectomy inthe Treatment of HyperacuteStroke

J Teitelbaum MDMNI

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Biography Professor, U de Montral

Associate Professor McGill U

Neurology & Neurocritical Care

Program Director: Neurocritical Care

Clinical Director: acute stroke program

Montreal Neurological Institute

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Disclosures

None

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ObjectivesRecognize physical exam findings that

would identify patients with a proximal arterial occlusion

Identify patients with stroke syndromes that would benefit from thrombectomy

Describe benefits and limitations of thrombectomy in stroke

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Case #1

Community hospital, only IM specialists

Called for possible stroke 1.5H after onset

67 yo male, HTN, DB,

ASA, lipitor, amlodipine, metformin

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Case #1

Doing weights at gym

Drops weight, L face crooked, dysarthria

Then weak L arm, trouble walking

Brought to ER

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Case #1

Alert, dysarthric, no aphasia

Gaze deviated to R, L facial droop

No movement L arm, weak in L leg

C / O pain R shoulder and neck

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Case #1

What are you thinking?

What else do you want to know?Hx Exam

Tests ?

Extra History

Neck pain before the fall or after?

Palpitations?

On Exam

Anosognosia?

Horner? Side?

Sensory exam? Cerebellar?

NIHSS ?

Tests

CT

CTA brain ?

CTA neck ??

CT Angiography:localization of the thrombus

What If ???

Case #2

58 yo man

No PMHx

Hospitalized for severe N & V, BP, H2O

Called because LOC

Case #2

Woke up dizzy, unwell

Gets up to go to the bathroomUnsteadyVomits several timesBack to bed & refuses to move

around

Exam in ER

Dix-Hallpike +

No facial asymetry

Moves all four limbs

Too much N & V to walk

Case #2Labyrinthitis, intoxication, gastro-

intestinalbut

This is a stroke course!!

Could this be a stroke??

How do you address this?

On Exam? CheckSpeech: dysarthria

CN: CornealEOM (III, IV, INO, nystagmus, pursuit)VII: central vs peripheral

abnormalityVIII

On Exam?

Motor: what might you find?NothingBilateral findingsBilateral Babinski sign

Cerebellar

Case # 2 Real ExamNot speaking, not obeying, blinking

Dolls: no lateral movement, pupils N

No grimace

Some flexion UE to central pain LUE > R

Triple flexion to peripheral pain

Case #2

What is the Dx ?

StrokeThird largest cause of death 14,000 deaths Women > men

50,000 strokes / year in Canada

315,000 people live with the sequelaeof stroke.

Stroke- CostsCanadian Economy: $3.6 billion/ y MD, hospital costs, loss of revenue, and

decreased productivity

Each year: 639,000 days in acute care hospitals 4.5 million days in long-term care

Central ischemic core

IschemicPenumbra

Anterior Circulation CVAClinical Picture

Aphasia / Dysarthria

Gaze deviation/ hmianopsia

Facial asymetry (naso-labial fold)

Weakness (numbness)

Posterior circulation CVAClinical Picture

Hx: N & V, dizziness (vertigo), unsteadiness, diplopia

Dysarthria

Abnormal ocular movements

Posterior circulation CVAClinical Picture

Face: N or upper motor or lower motorVII

Weakness: uni ou bilateral, or 2 legs

Often: Babinski one or 2 sidesAtaxia / dysmtria

DiagnosisClinical pictureShould fit a vascular territory

CT head C-often N

CTA (MRI)

Why CTA Is our Dx always correct? Errors Stroke mimics Indication for thrombolysis / thrombectomy

Reveals pathophysiology

Mild or resolving CVA May have large vessel occlusion

Stroke Mimics ICH, SDH, Vasospasm

Arterial dissection

Hypoglycemia (HyperG; Na+; liver)

Post-ictal

Tumor, infection, abcess

non-organic (conversion or malingering)

Mimics with N CTArterial dissection

Vasospasm

Hypoglycemia (HyperG; Na+; liver)

Post-ictal

Non-organic

Diagnostic error< 50 years: 20 % migraine ER doc: 40% Neuro: 19%

> 50 years: 5% Post-ictal

Worse for TIA

CT Angiography:localization of the thrombus

NEJM.org Feb 15,2015

CTA: The Collaterals

Multiphase CTA: 5 secs

Early Phase Intermediate Phase

What can we do??

Better outcome withRapid diagnosisRapid IV thrombolysis Dedicated stroke units

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ThrombectomyIn Acute Stroke

Ischemic StrokeTreatment ad 2015

IV ThrombolysisCVA< 4.5 HEfficacy?

MechanicalIntervention 2013

NEJM- IMS III- MR RESCUE- SYNTHESIS

clear benefit to date

However

52

0%

15%

30%

45%

60% 58%

14% 14%25%

41%

13%

RecanalisNon-recanalis

Good outcome MortalityHIC Sx

The Impact of Recanalization on ischemic stroke outcomeA Metanalysis Stroke 2007 38(3) 967-73

Rates of recanalisation With iv TPA

Global (proximal occl) 21%Distal Internal Carotid 8% 4,4%M1 (origin of MCA) 26% 32%M2 38% 31%M3 75%Basilar Trunc 4%

Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010 41(10):2254-2258. Bhatia R, Hill MD, et al.

1h Post 2h post

M1M2

M3

M3Carotide

ACM

Rates of recanalisationWith iv TPA

Thrombus > 8mm 0

Thrombus 0 - 5 mm 42%

2h post

Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call foraction. Stroke. 2010 41(10):2254-2258. Bhatia R, Hill MD, et al.

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Recent Studies (7) MR CLEAN (Pays Bas)

ESCAPE (Can, EU, GB, Kore S)

EXTEND IA (Aus, NZ)

SWIFT-PRIME (EU + Europe)

REVASCAT (Espagne)

THRACE (France)

THERAPY (EU)

Nov 2014 NEJM

Feb 2015 NEJM

Feb 2015 NEJM

March 2015 NEJM

March 2015 NEJM

Euroean Cong CVA 3/2015

European Cong CVA 3/2015

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Basic Setup of All StudiesProximal clotAnterior Circ.

Viable Penumbra

Collaterals

Poor Response to Lysis

Thrombolysis

Thrombolysis*+

Thrombectomy

Size CVA

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mRankin 0-2 (90j)Absolute Diff.

Thx+ TPA > TPA NNTMR CLEAN 14% 7,4ESCAPE 24% 4EXTEND IA 33% 3SWIFT- PRIME 24,5% 4REVASCAT 15,5% 6,5THRACE 12,1% (8,2)THERAPY 7,6 % (NS) -

* NINDS: mRS (0-1) 12-13% NNT 7,5ECASS-3 (4,5h) mRS 0-2 = 7% NNT 14

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ESCAPE

0 - 2 3 - 4 5 - 6

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Rate of recanalisation

(59 - 88 %)72%

TPA + Thrombectomy TPA

8 - 33%

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Therefore

All studies are + Clear important in autonomous patients

NNT impressive (4 - 7,5)

Patients had worse strokes than NINDS

ICH

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Patient selection Presence of a proximal clot Small infarct territory Viable penumbra

Better Technology Expertise Recanalisation rates Delay

WhyIs it working this time round?

ESCAPE, EXTEND IA SWIFT-PRIMENNT 4, 3, 4

The question

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Proportion of eligible patients?

10 - 15 % Estimated eligibility

Type to enter textNIHSS > 10 Proximalocclusion85%

According to severity

Who?

Be familiar with NIHSS

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NIHSS level of conscience 1-6

Hemiplegia Face 1-3 Arm 1-3 Leg 1-3

Complete Hemianopsia 2

Aphasia 1-2

Sensitivity 1-2

Extinction

Dense hmiplegia = 11

Marked 1/2 paresis + VF = 10

Moderate 1/2 paresis+ VF+ aphasia = 10-11

Type to enter textCT ?

vidence of a large ncrotic centre

? Hyperdense MCA

+ Results of CT-Angio ? Proximal clot

Who?Moderate to severe stroke

Hyperdense MCA Sign

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Posterior Circulation?

Basilar artery stroke

Mortality up to 80%

Yes!

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Window?4,5 h ?6 h ?

Where to sendStroke patients ?

Who to sendwhere?

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System Re-organisation

Regionalisation of Tx for acute strokes

Secondary centres (CVA) Tertiary?

Straight to tertiary centres ???

Drip and ship

Mother ship

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So

If you think it is anterior circulation stroke

Check: Face (asymetry) Visual fields (hemianopsia) Strength (unilateral weakness)

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So If you think it is anterior circulation stroke

AND IF < 6H (up to 10H) or wake-up stroke With Dense hmiplegiaMarked 1/2 paresis + VF Moderate 1/2 paresis + VF+ aphasia

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Then

This is a big stroke

85% chance of large vessel thrombus

Start TPA IV, ambulance STAT

Straight to tertiary center

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Or If on history: Nausea, V, Dizzy, vertigo, unsteady Diplopia,

If on exam Dysarthria, nystagmus, abnormal EOM Ataxia, dysmetria Bilateral weakness (legs)

Think posterior circulation, basilar artery

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Then

Posterior circulation stroke may deteriorate

Usually requires ICU monitoring 24-48H

TPA IV is indicated

Tertiary center, possibly secondary

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Or

Mild stroke (NIH < 10)

More than10H from onset

Not sure of diagnosis

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Then

Secondary stroke center

Nearest ER

Stroke prevention clinic

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Tertiary Centers

Montreal Neurological Institute

Notre-Dame

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Tertiary Centers

Montreal Neurological Institute Call 934-1934 then 1 Then 44743

RED Unit MD (Neurointensivist) Describe your case Transfer the patient

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Questions ?

Thombectomy inthe Treatment of HyperacuteStrokeBiographyDisclosuresObjectivesCase #1Case #1Case #1Case #1Extra HistoryOn ExamTestsSlide Number 12Slide Number 13Case #2Case #2Exam in ERCase #2On Exam? CheckOn Exam?Case # 2 Real ExamCase #2 Slide Number 22Slide Number 23StrokeStroke- CostsSlide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Anterior Circulation CVAClinical PicturePosterior circulation CVAClinical PicturePosterior circulation CVAClinical PictureDiagnosisWhy CTAStroke MimicsMimics with N CTDiagnostic errorSlide Number 45Slide Number 46Slide Number 47What can we do??Thrombectomy In Acute StrokeIschemic StrokeTreatment ad 2015Slide Number 51Slide Number 52Slide Number 53Rates of recanalisation With iv TPA Rates of recanalisation With iv TPASlide Number 56Recent Studies (7)Basic Setup of All Studies Slide Number 59ESCAPERate of recanalisationThereforeSlide Number 63Slide Number 64Proportion of eligible patients?Who?NIHSSWho?Hyperdense MCA SignPosterior Circulation?Slide Number 71Slide Number 72 System Re-organisationSoSoThenOrThenOrThenSlide Number 81Tertiary CentersTertiary CentersSlide Number 84Questions ?