interventions in stroke-evidence based management

1Copyright © 2015 Dr. Vipul Gupta . All rights reserved. 1

Head, Neurointerventional Surgery &Interventional NeuroradiologyNEUROVASCULAR & STROKE CENTRE,Medanta-The Medicity

Dr Vipul Gupta

Interventions in stroke:Interventions in stroke:Evidence based managementEvidence based management

2Copyright © 2015 Dr. Vipul Gupta . All rights reserved.

Neurovascular diseases…Stroke…. Third most common cause of death Most common reason for disability Appx. 1 in 4 people die within 1 year 30%–50% do not regain functional

independence Annual incidence rate of stroke in India

currently is 145 per 100,000 population 10 - 15% occur in < 40 years

WHO estimates suggest that by 2050, 80% stroke cases in the world would occur in low and middle income countries mainly India and China


Endovascular neurointerventions !!!

Disease states different End- organ different- every area

important Reactive organ- reperfusion-

bleed Arteries different Access difficult- tortuosity


Neurointerventions…

SAH- aneurysms, vasospasm Intracerebral hemorrhage- AVMs TIA- major vessel stenosis E/C & I/C Stroke- revascularization

Diagnosis- Imaging Interventional hardware Integrated approach


ISCHAEMIC stroke- brain attack

Penumbra

• At 60 min, about 90%• At 2 h about 80 %• At 3 h about 60% and • At 4.5 h about 40% of patients

Thereafter ?• Maybe 30% at 9 h • And less than 20% beyond 12 h


Penumbra and Treatment Options

0

10

20

30

min

CB

F (m

l/100

g/m

in)

300 9060 4120 5 6 24 48h

Infarct-threshold

Penumbra

Normal Vital tissue

InfarctSingle cellnecrosis

3


IV tPA- indicationsASA/AHA guidelinesStroke - 2013

Less than 10% patients are eligible


Issues with IV tPA

Time factor Large vessel disease Time to recanalize C.I. – anti-coagulants, recent surgery, wake-up strokes…. < 5 % qualify


CT, CTA, CTP….

CT perfusion imaging

MTTCBF CBV

CBV – 2ml/gm- infarcted core; CBF, MTT - hyoperfusion area

Concept of Penumbra

CBF/MTT CBVMatchedNo penumbra

CBF/MTTCBV

penumbra

CTA & CTP vs MR DWI & PWI


Imaging approaches for case selection

NCCT (ASPECTS)- NIHSS NCCT & CTA, CTA-SI NCCT, CTA & CTP MRI-DWI, (MRA, PWI)

What information is needed?• Bleed• Infarct core – is critical 70-

100 ml• Major vessel occlusion• Tissue at risk- penumbra

Time, imaging interpretation, unstable patients


Evidence – 2014-2015

IMS-III, MR RESCUE & Synthes – failed- no appropriate imaging and old devices Recent trials – imaging for MVO & stent- retreviers MR CLEAN – strongly positive ESCAPE – stopped bcs of efficacy EXTEND –IA – positive DRAMATIC CHANGE IN MGT OF STROKE

MR CLEAN(Netherlands)

ESCAPE(CANADIAN)

EXTEND IA(AUSTRALIAN)

SWIFT PRIME(USA)

REVASCAT(SPANISH)

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

• Documented MVO.- ICA, MCA (M1, M2)• Time based: 6 hrs (initiation of IA therapy)-

(8 hrs – REVASCAT; 12 hrs – ESCAPE)• Small Core - CT ASPECTS ≥ 6• CTP – EXTEND IA; SWIFT PRIME

• Predominantly stent retrievers. • 86.1 to 100% (100 % in EXTEND IA &

SWIFT PRIME)• (NIHSS scores were 17 (interquartile range,

13–21)

TICI 2B/3 – 59% - 88% - (previous trials 25%, 41%)

Recanalization – TICI 2B/3

Absolute Benefit (good outcome) : 13.5% to 31.4%(Statistically significant)

mRS (90 d)

no significant difference

sICH

Device complication

Absolute mortality benefit : 8.6%(Statistically significant in ESCAPE)

Mortality

Comparison of NNT:

EVT: NNT (benefit) - 3.1 to 4.2 (excluding MR CLEAN)

IV tPA ( 3 – 4.5 hours) – 13.8 (ECASS – 3)

Primary PCI (prevent re-infarction) – 33


Clinical … Left hemiplegia, left UL and LL 0/5 5:14AM


6:22AM

8:07 AM

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


63 /M, AVR, Coumadin INR of 2.5 RT hemiparesis - 2/5 in leg

and 0/5 in arm Global aphasia

CBF CBV

Solitaire stent was deployed


Patient presented with in 2 hours

Futile IV tpa

AHA/ ASA guideline 2015:Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):

prestroke mRS score 0 to 1 acute ischemic stroke receiving intravenous r-tPA within 4.5

hours of onset causative occlusion of the internal carotid artery or proximal

MCA (M1) age ≥18 years NIHSS score of ≥6 ASPECTS of ≥ 6 treatment can be initiated (groin puncture) within 6 hours of

symptom onset

AHA/ ASA guideline:Carefully selected patients with anterior circulation occlusion who have contraindications to intravenous r-tPA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable (Class IIa; Level of Evidence C).

Carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries (Class IIb; Level of Evidence C)

Waiting after IV tPA not required (Class III)

Beyond 6 hours – Should you consider MT?

ESCAPE: up to 12-hours – positive trial

6 hours49 patientsrate ratio, 1.7; (95% CI, 0.7 to 4.0)

Not significant; however few numbers.

REVASCAT: upto 12 hours, positive trial

Data not provided.


• 60 years old female.Acute onset left hemiparesis and left facial weakness; CT Brain , CTP and CTA done 6 1/2 hours after ictus.


Our results Total No. of patients= 42 (M-19, F- 23) Time of arrival: 30 min- 840 min (mean 203.8 minutes) NIHSS at admission: 5-22 (Mean 14.33) MVO 39, IV tPA- 19

Good recanalization (TICI 2b or 3) in 57.1%mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)

Recanalization V/s Outcome


ANEURYSMS- basic facts

• Subarachnoid hemorrhage (SAH).• One in every 20 strokes , at the

prime of ones life (commonly between 40-50yrs).

• Up to 40-50% patients do not survive even for a month mostly because of the rerupture of the aneurysm

• With proper treatment up to 90% of patient who reach hospital before any major damage has happened will lead an independent and productive life

Initial CT Scan

Rebleeding after 1 day


Clipping vs coiling… Initially Surgically inappropriate Tremendous changes in last 15-yrs

Cerebral Aneurysms-

• Image-guidance (3-D , Dyna-CT)• Coil, catheter, balloons, stents • Drugs- aspirin, clopidogrel,

abciximab• Appx. 90% by endovascular • Intra-arterial vasospasm mgt.

• HELP and Cerecyte studies – mRS 0-2 in 87% (80% in ISAT)


ISAT Randomized, prospective, international trial Clipping vs coiling ISAT follow-up, Lancet 2014- at 9 yrs,

outcome better

Guidelines for the Management of Aneurysmal SAH: Special Writing Group of the Stroke Council, ASA/AHA Stroke 2009

Amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling can be beneficial (Class I, Level of Evidence B).

Metanalysis- Stroke 2013, AJNR 2013• Ruptured aneurysms- better outcomes after endovascular management

Broad neck aneurysmBroad neck aneurysm

Balloon assisted coiling

Stent assisted coiling

Dissecting blister aneurysm – poor gradeEVD

2-overlapping Enterprise stents 6-months follow-up

Blister/dissecting aneurysms

Very small aneurysms

Flow diverters (stents)- no coils


Vasospasm- 15-25% morbidity and mortality

Day 7

Continuous intra-arterial dilatation

Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.Anand S, Goel G, Gupta V.J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]

http://www.ncbi.nlm.nih.gov/pubmed/23774116

http://www.ncbi.nlm.nih.gov/pubmed/23774116


Our protocol Interventionist part of

neurosurgery team DSA & if possible embolization Neuro lab with 3D, CT NS ICU monitoring (TCD/CTP). Vasospasm- IAVD N- 706 (Sept 2014) Data of consecutive patients


Our protocol Interventionist part of

neurosurgery team DSA & if possible embolization Neuro labwith 3D, CT NS ICU monitoring (TCD/CTP). Vasospasm- IAVD N- 540 (Jan 2014)

EmbolizationSurgery

91%

9%

Good outcomeFNDMortality

Mgt. outcome in good grade patients- 90 % mRS 0-2


CAROTID ARTERY STENOSIS- 20-25% STROKES BY MAJOR VESSEL STENOSIS

Symptomatic Stenosis Symptomatic Stenosis • Non-invasive >70% Non-invasive >70% • Catheter angiography >50% Catheter angiography >50% • Peri-procedural risk <6%Peri-procedural risk <6%

Asymptomatic Stenosis Asymptomatic Stenosis • >70% Stenosis>70% Stenosis• Periprocedural complication risk is low Periprocedural complication risk is low • Life expectancy >5 yrLife expectancy >5 yr• >80% stenosis- tend to be treated>80% stenosis- tend to be treated

Revascularization indications-Revascularization indications- ASA/AHA guidelines 2011ASA/AHA guidelines 2011

STENTING FOR SEVERE CAROTID STENOSIS

Patient with TIAs…..stenting done the next day

Should be done as soon as possible…maximum stroke risk in first few weeks


CAS vs CEA- CREST – NEJM 2011

•2502 patients- Outcome largely same•More MI in surgery ; more minor strokes in CAS•Stenting better in 70yrs and less age group •Nerve palsies not included in end-points•Less than 1% major stroke

ASA/AHA guidelines 2014- Endarterectomy and stenting are alternatives (Class I evidence)<70 yrs, stenting may be preferable


• Microemboli• Plaque morphology• Vasomotor reactivity• Silent infarcts • Progression


Transient ischaemic attack

• Meta-analysis of 11 observational studies: Risk of stroke at 2, 30 and 90 days after TIA was 9.9,

13.4 and 17.3% respectively• Pooled analysis of 3206 pts with TIA and DWI

imaging, risk of stroke at 7 days was much lower in those without infarction compared to those with infarction: 0.4% vs 7.1%

Coull et al. BMJ 2004

Minor Cerebrovascular Syndrome


ABCD3 ABCD3 – I score Multicenter pooled analysis:

UK + Ireland for Derivation model

Oxfordshire (UK) + California (US) for Validation model


TIAs/minor stroke High risk of stroke in first few weeks Patients with DWI lesions and arterial stenosis have

higher risk Revascularization should be done soon


CT Delayed …..

Intracranial atherosclerosis Intracranial arterial stenosis is responsible for 6%

to 10% of ischemic strokes in whites and 22% to 26% of ischemic strokes in Asians

SAMPRIS Trial- stenting not to be done as routine in acute stroke

•Recurrent symptom•Subocclusive stenosis


Clinical- Bleeding Seizures Neurological deficit Headaches Incidental

Cerebral Cerebral Arteriovenous Arteriovenous malformationsmalformations


AVM- treatment options

Embolization Radiosurgery (Gamma Knife, LINAC, Cyberknife) Surgery

Embolization Glue (NBCA) vs Onyx embolization


Conclusion

Advances in Neuroimaging and neurointervention

Critical role in mgt of SAH-aneurysm, Acute stroke, TIA- carotid stenosis, ICH-AVMs

Latest trials have proven the role in acute stroke

Neurointerventionist, neurologist, neurosurgeon and radiologist as a team


Exciting time in neurosciences …

Interventional treatment methods for diseases like epilepsy, parkinsonism, headaches …..

Image guidance in neurosurgery Radiosurgery – Gamma Knife , Cyberknife Minimally invasive spine and brainsurgery Rapid evolution in approach Multidisciplinary , team approach


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Dr Vipul Gupta

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interventions in stroke-evidence based management

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