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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