WHERE TO GO AND WHAT TO

CHASE: ENDOVASCULAR

UNCERTAINTIES

Michael G. Abraham, MD, FAHAAssistant Professor

Neurointerventionalist & Neurointensivist

Disclosures

• Speaker’s Bureau – Boehringer Ingelheim

• Consultant – Stryker Neurovascular

Objectives

• Stroke trials and scales

• EVT uncertainties

• Stroke routing

Immediate Decisions

• Stroke intervention begins the moment symptoms

start

• Family member, friend, stranger, transferring nurse, transferring

physician, EMS, accepting physician/nurse/resident

• ~2 million neurons die per minute

• Every 30 minutes of no flow 10% worse outcome

Golden Hour for IV tPA in AIS

I. STROKE TRIALS AND

SCALES

mTICI 2b/3 90 day mRS ≤2 (EVT vs

SC)

IMS 3 23-44% 40.8% vs 48.7%

MR RESCUE 25% 12% vs 11%

SYNTHESIS-

EXPANSION

Not reported 30.4% vs 34.8%*

MR CLEAN (6) 58.7% 32.6% vs 19.1%

SWIFT PRIME (4.5) 88% 60% vs 35.5%

ESCAPE (12) 72.4% 53% vs 29.3%

EXTEND-IA (6-8) 86% 71% vs 40%

REVASCAT (8) 66% 43.7% vs 28.2%

2015 AHA/ASA Focused Update of 2013 Guidelines for

Early Management of Patients With AIS Regarding EVT

• EVT with stent retriever (SR)

• (a) pre-stroke mRS ≤1

• (b) AIS receiving IV tPA <4.5

hours according to

guidelines

• (c) occlusion of ICA or M1

• (d) ≥18 years

• (e) NIHSS ≥6

• (f) ASPECTS ≥6

• (g) treatment can be initiated

(groin puncture) ≤6 hours

• Class I, Level of Evidence A

http://stroke.ahajournals.org/content/early/2015/06/26/ST

R.0000000000000074

Stroke Scales

• Mathew Stroke Scale (1972)

• Prehospital Acute Stroke Severity (PASS)

• Minnesota Prehospital Stroke Scale (MPSS)

• Large Vessel Occlusion Scale (LVOS)

• Canadian Stroke Scale (CSS)

• Orgogozo Stroke Scale

• European Stroke Scale

• Hemispheric Stroke Scale

• Field Assessment Stroke Trial for Emergency Destination (FAST-ED)

• Cincinnati Prehospital Stroke Severity Scale (CPSSS)

• Los Angeles Motor Scale (LAMS)

• Rapid Arterial oCclusion Evaluation (RACE) scale

• Vision, Aphasia, Neglect (VAN)

• Miami Emergency Neurological Deficit (MEND)

• National Institutes of Health Stroke Scale (NIHSS)

CPSSS• 0-4: ≥2 was 89% sensitive and 72% specific in

identifying NIHSS ≥14 or moderate/severe stroke

Los Angeles Motor Scale (LAMS)• Score ≥4/5 showed

sensitivity 81%/

specificity 89% in

identifying LVO

Rapid Arterial oCclusion Evaluation (RACE)

• Highly predictive of LVO

• Sensitivity 85%/specificity

65% with cutoff of 5/9

VAN• Vision, Aphasia, Neglect

• Positive or Negative for

LVO

• Patient must have

weakness plus one or all

of the V, A, or N to be

positive

• Validated only in ED

Miami Emergency

Neurological Deficit

(MEND)

• Does not predict LVO

NIHSS

• Strong predictor of clinical outcome

• >10 highly correlated with LVO that may require EVT

• 0-42

0 – Normal function

1-4 = Mild deficit

5-15 = Moderate deficits

16-20 = Moderate to severe deficits

21-42 = Severe

Rymer, MM., Thrutchly D. The Role of Stroke Severity in

Transfer and Treatment Decisions. Stroke Vol 39, No 2

February 2008. p.608

• Compare NIHSS (sub-scores) and other

scores to predict LVO on CTA/MRA

• NIHSS, RACE, 3I-SS, sNIHSS-8, sNIHSS-

5, sNIHSS-1, mNIHSS, a-NIHSS (profiles

a-e), CPSSS

“Mission Impossible” Results

• 1085 consecutive patients

• intersection of sensitivity and specificity curves, best total

NIHSS score for LVO was 7 (PPV 84.2 %, sens 81.0 %,

spec 76.6 %, NPV 72.4%)

• total NIHSS showed lowest percentage of patients with

LVO missed at the intersection of the sensitivity and

specificity curve (19.0 %)

• 9% with NIHSS ≤4 had an LVO

“Mission Impossible”

• In all simple clinical scores, no clinically relevant cut-off

value could be found to reliably exclude LVO

• Combinations of NIHSS sub-items and all published

scores were equally or less predictive to show LVO

• Best OR among different NIHSS sub-items to predict LVO

• best gaze (9.6, 95 %-CI 6.765–13.632), visual fields (7.0, 95 %-CI

3.981–12.370), motor arms (7.6, 95 %-CI 5.589–10.204), and

aphasia/neglect (7.1, 95 %-CI 5.352–9.492)

“Mission Impossible”

• RACE applied to cohort >50% of patients with LVO as

defined in study would have been missed at a cut-off of 6

• CPSSS applied to cohort >50% of patients with LVO as

defined in study would have been missed at cut-off of 2

• Unable to find a reasonable cut-off value with a high

specificity for LVO without missing a sizable number of

patients with LVO in all published and our own scores

“Mission Impossible”

• LVOs observed in relevant number of patients with low

NIHSS scores at presentation or with rapidly improving

symptoms (false negative)

• Vessel imaging should be performed in patients with low

scores, since EVT might also be effective in patients with

mild deficits and LVO

Case #1

• 51 year old female with waxing/waning right sided

hemiparesis and aphasia

• Initial NIHSS 9 5 6

Case #1

Case #2

• 70 year old female with a history of HTN, tobacco use,

and alcohol use presented on 12-27-12 at 7:00 pm with

altered mental status

• brought to ED

• unable to complete sentences and slurring words

• stroke activation – NIHSS 2

• 7:15 pm – CTOH

• negative for hemorrhage or ischemic stroke

• respiratory distress

• intubated and sedated

• Admitted to MICU

• found to be in a fib (new diagnosis)

• Loaded with Digoxin

• MRI-brain ordered due initial stroke symptoms

• 10-28-12 at 7:00 am

CT-angio to evaluate for vertebral artery dissection

– 10-28-12 at 3:00 pm

20 hours

Left vertebral artery injection - 10-28-12 – 9:00 pm

Final angiogram

Posterior Circulation Strokes

• diplopia, dysphagia, gait instability, hearing, and

nystagmus not get evaluated with NIHSS

• 20% of ischemic and hemorrhagic strokes

• 80% death/disability rate

• EOM: horizontal, vertical

• Nystagmus and/or Horner’s syndrome = 1

• Facial: say “ahh”

• Soft palate/tongue paralysis = 3

• Ataxia: sit up

• Latero/retropulsion = 2

• Sit stand Romberg = 1

e-NIHSS

• 47 patients

• 22 suspected PC

• Intra-reliability of each item of e-NIHSS and inter-reliability

of total e-NIHSS between 2 independent observers

showed statistically significant accordance

• 0.933 and 0.930

• PC stroke scores averaged 2 points higher

• Nystagmus, Horner’s syndrome, and IX/XII deficit more

specific items for PC stroke than trunk ataxia and

Romberg

Israeli Vertebrobasilar Stroke Scale

• 11 items

• 44 highest

• 6 minutes

• All patients tested by IVBSS, NIHSS, and mRS during

same evaluation

• Assessed by two certified NIHSS examiners

independently

• >8 severe vertebrobasilar artery stroke

• High inter-rater reliability

• Validated to NIHSS and mRS

II. EVT UNCERTAINTIES

AHA/ASA EVT Recommendations

• EVT with SR may be reasonable for carefully selected

patients with groin puncture ≤6 hours with M2, M3, ACAs,

VA, BA, or PCAs occlusion (Class IIb; Level of Evidence

C)

• SR preferred to MERCI device (Class I; Level of Evidence

A)

• Devices other than SR may be reasonable in some

circumstances (Class IIb, Level B-NR)

http://stroke.ahajournals.org/content/early/2015/06/26/STR.0000000000000074

• 5 EVT

• 94 pts (51 EVT)

• Multicenter retrospective cohort

• M2 segments, 8 hours LKN

• 522 patients

• 288 EVT (SR, aspiration, tPA), 234 MM

JAMA Neurol. 2016 Sep 12. doi: 10.1001/jamaneurol.2016.2773

M2 and Beyond

• Baseline Demographics

• MM older, more IV tPA, earlier presentation

• NIHSS and ASPECTS same

• mRS ≤2: 62.8% vs 49%

• SICH (5.6% vs 2.1%, ns)

• 3.1 OR for EVT

• Treatment effect did not change per institution

• Younger age, lower admission NIHSS, higher ASPECTS,

shorter time to reperfusion, >2B better outcomes in

EVT

JAMA Neurol. 2016 Sep 12. doi:

10.1001/jamaneurol.2016.2773

• 98 patients, 6 institutions

• TICI 2B/3 = 78%

• With stent retriever 95% (Solumbra)

• Average groin-puncture 37 minutes

• 90 day mRS ≤2 - 40%

• 0.060, 0.064, 0.068, 0.070

J NeuroIntervent Surg doi:10.1136/neurintsurg-2014-

011125

• Solumbra group

• ADAPT group

• No strict time window

• ASPECTS ≥6

• CTA not required

• Elderly done

• Young - no if LKW ≤6, high NIHSS

J Neurointerv Surg. 2016 Nov;8(11):1123-1128. doi: 10.1136/neurintsurg-2015-012122. Epub 2015

Dec 14.

J Neurointerv Surg. 2016 Nov;8(11):1123-1128. doi: 10.1136/neurintsurg-2015-012122. Epub 2015

Dec 14.

J Neurointerv Surg. 2016 Nov;8(11):1123-1128. doi: 10.1136/neurintsurg-2015-012122. Epub 2015

Dec 14.

• 73 year old female status post gastric surgery 3 days

prior

• Walking in hospital unit and fell at 16:20

• Stroke activation

• CT-angiogram

• CT-perfusion not done as within 3 hours

20 minutes from

groin puncture

MRI - DWI

BASICS Registry

• Prospective,

international registry

• 592 patients

• 183 AT

• 121 IVT

• 67% with TCD

• 288 EVT

• 72% TIMI 2/3

• 32% mRS ≤3

• Estimated time of

onset consistent with

clinical diagnosis of

BAO rather than time

of onset of any

symptom

• Previous studies:

BAO preceded by

prodromal symptoms

in >60%

• 38 patients, retrospective, CSC

• Mean age 58 years

• 27 IV tPA

• 30 EVT, ≥12 hours

• Median NIHSS 21

• Treatment

• Trevo, Merci, ReVive, Solitaire, Catch, Urokinase

• 15 combo

• Time to recanalization 288 minutes

• TICI 2B/3 -91%

• mRS ≤3 - 50% (30% BASICS)

• mRS ≤2 - 37%

• Mortality 39%

• No a/w patent collaterals and favorable outcome

• 15 only mechanical – no ICH

• ICH 5% - IA urokinase/IV tPA

• Significantly better outcomes: <65, NIHSS< 20

• No multivariate analysis

• Sub-acute infarcts excluded

• 22 - Solitaire

• 10 in coma; mean NIHSS `13.6

• general anesthesia 73% and conscious sedation 27%

• median recanalization time 8 hours

• 41% stenosis ≥70%, 8 angioplasty and 1 stenting

• TICI 2b/3 in 73%

• 27% 90-day mRS ≤2, 45% died, and 14% hemorrhage <24 h

• Favorable outcome: younger age (47 vs 66 years; p=0.0003) and distal third BAO (41% vs 0%, p=0.05)

• Meta-analysis – 312 pts

• IV thrombolytic before EVT (mean 38.7%)

• Solitaire (Revive, Penumbra, IA rt-PA)

• Admission NIHSS 11-26.3

• Mean time to recanalization was 8 h (5.5– 13.6)

• TICI ≥2b 81%

• 90 day mRS ≤2 – 42%

• 30% mortality at discharge or after 3 month follow-up

• SICH 4%

KUMC EVT Cohort

• Posterior n = 26

• Anterior n =81

III. STROKE ROUTING

Stroke Patient

Local ED/Urgent

Care

CSCPSC

1

2 3

4

Prep Time

• ED bed: 10-15 minutes

• OSH bed ambulance: 10-15 minutes

• Additional equipment setup (transport IV infusion pumps,

ventilator): 20-30 minutes

• 30-60 minutes additional time

• Aim: shorten time to EVT

• Pre-intervention – 10 months

• Post-intervention - 18 months

Methods

• Eye deviation, awake, arm or leg paretic and not anti-

gravity, language

• Yes to 1+2 or 2+3+4

• Transported directly to CSC, bypassing nearer PSC

• Hospitals pre-notified routinely

• 476 patients received revascularization

• 153 323

• M1, M2, ICA, basilar

• EVT – NIHSS >10, <6 hours, pre-mRS <1

30-60

minutes

Results

• System Delay: Pre-hospital and in-hospital delays

• Treatment Delay: symptom onset to treatment initiation

• EVT median system delay 234 min 185 min

• Occurred in pre-hospital and in-hospital phases

• Determine period in which EVT is associated with benefit

and to investigate extent to which treatment delay is

related to association of EVT with functional outcomes,

mortality, and SICH

• 1287 pts (634 EVT)

• time at which estimated treatment benefit first crossed 1.0

was at 7 hours and 18 minutes

• delay in symptom onset to reperfusion times associated

with increased 3-month disability

• every 9-minute delay in symptom onset–to–substantial

endovascular reperfusion time, 1 of every 100 treated

patients had a worse disability outcome (≥1 on mRS)

• for every 4-minute delay in ED door-to-reperfusion time,

1 of every 100 treated patients had a worse disability

outcome

• Stroke scales

• Earlier recognition of LVO

• Routing

• Transfer times

• Appropriate destination

• Uncertainties

• Basilar artery sensory only?

• PCA vision only?

• Other devices

Fight stroke like Jedi knight...