The use of thrombectomy and the

stroke network organization

ESC Stroke Council

2017

Pr. Christophe Cognard

University of Toulouse

Three levels of Evidence based

Medecine in acute stroke care

1. Hospitalization in a stroke unit: 100%

patients

2. IV t-PA: 10 to15%

3. Mechanical thrombectomy : 5 to 7 %

In 2015, seven randomized clinical

trials have shown the tremendous

efficacy of endovascular treatment

of acute stroke

mRs 2 at 3M

MT / IV in all studies

Odds ratio: 2.29

Today thrombectomy is

recommended

for LVO Stroke

of the anterior circulation

up to 6h after onset

European Consensus Statement on Thrombectomy(International Journal of Stroke)

ESOKSU

The things we know !

Thrombectomy must be performed in

LVO strokes

1) Anterior circulation

2) Even > 80 Y

3) In the first 6 h

4) After IV or not

No age limit

Even for M2 occlusion

But need case by case discussion

NIHSS / Proximal or distal M2 ?

Even in the posterior circulation (No

Evidence)

The things we don’t know!

The RCT we need

6 positive RCTs have answered one

question

And have risen a lot of

questions

We will not have from the 6 RCTs the

answers of the questions these RCTSs were

not designed to answer to

1) Should we do thrombectomy after

6 hours?

In which patients

Need for a RCT !

When to decide it is too late to do the

thrombectomy?

Slow/Rapid progressors!

There are futile very early recanalization < 4h

But useful late recanalization > 6h

Or only rely on imaging parameters ?

Two ongoing trials

Dawn and Defuse 3

Should we consider time from onset ?

2) Should IV be performed before

thrombectomy in LVO strokes ?

Need for a RCT !

In favor of IV:

• IV TPA may obtain a recanalization in 5 to 10% (specially if

short thrombus or residual flow)

• Distal thrombus migration (M1 to distal M2): early

neurologic improvement

• Softening thrombus for thrombectomy (less passes, less cost,

shorter procedure) ?

• Reperfusion of persisting distal emboli post thrombectomy !

Why not IV after thrombectomy in

LVO strokes ?

Against IV:

• IV t-PA Cost

• More symptomatic hemorrhages within/without the

infarct

• Increased delay to thrombectomy (drip and ship +++)

• Proximal thrombus migration

• Carotid stenting during EVT and need for immediate

antiplatelet therapy

Should IV t-PA be performed before

thrombectomy in LVO strokes ?

Need for a RCT !

3) Should the patient go in the nearest

stroke unit or directly to the thrombectomy

center?

Need for a RCT !

3) Should the patient go in the nearest

stroke unit or directly to the thrombectomy

center?

REVASCAT 2

Need for a RCT !

The future ?

All patients with NIHSS > 9 directly referred to

a thrombectomy center without IV TPA

No imaging but angioroom / Xpert-CT / Thrombectomy

Imaging only:

> 6h

NIHSS < 9

Stroke network in France

• 65 Million inhabitants

• 138 Stroke Units since 2007 (by law)

• 36 centers of INR (most in University

hospitals)

• INR centers connected to Stroke units by

telemedicine

Numbers of MT in France

• 2015:

1607

• 2016:

3671

And in 2020?

5 000 ?

10 000 ?

10 000 MT in France

277 MT per centre

And in 2020?

130 000 strokes in France/ Year

MT: 5 to 7 %

6 500 to 9 100 TM

116 000 coronary stenting in

2010!

In 2020,

endovascular treatment of brain

stroke

will represent around 7%

of endovascular treatment of cardiac

stroke

How many INR in France?

• Around 100 senior INR

• 36 fellows

• Number of INR per centre: 2 to 6

• Need for at least 4 INR per centre (144 in

France)

• Up to 6 in big centers

• So finally between 150 et 200 INR needed

in France

Thrombectomy in France

• MT only done in comprehensive INR centers

• Only by fully trained INR specialists

• 70% imaging done by MR

• 50 % MT done under GA

Thrombectomy in France:

Should we open new centers ?

• Why ?

• Some stroke units are too far away from INR

centers (>150 Km, > 1h)

• Or should we buy helicopters ?

Thrombectomy in France:

Should we open new centers ?

• Conditions for opening new centers:

– Must be > 150 Km or > 1h from the INR center

– Must do > 150 IV thrombolysis a year (80 MT)

But only very few do > 150 IV/Year

Requirement for opening a new

thrombectomy center (MT only)

• 24/7 Vascular neurologist (on call?)

• 24/7 Interventionist

• 24/7 CTA/CTP, MRA/MRP

• 24/7 Angioroom

• 24/7 Anesthesiologist

• 24/7 Neurosurgeon ?

Requirement for a thrombectomy

procedure

• 24/7 Interventionist: need for 4

• 24/7 Anesthesiologist

• 24/7 Technician

• 24/7 Nurse

What are the numbers in

Toulouse

• 2013: 50

• 2014: 80

• 2015: 180

• 2016: 240

• 2020: 300? 400?

3 Millions inhabitants

One thrombectomy center

12 Stroke Units

20 hospitals

1

2+

1

3

6

5

11

6

10

116

3

In 2015: 180 Thrombectomies done in

Toulouse

What are the numbers of patients addressed

for a MT to ToulouseUNV NO

PPR CHU 116Rangueil RANG 4Clinique des Cèdres CDC 3Saint-Gaudens SG 6CHIVA CHIVA 3Carcassone CARC 10Rodez RODEZ 1Auch AUCH 5Cahors CAHORS 3Tarbes TARB 11Albi UNV CHG ALBICHG 2ALBI UNV Cl. Bernard ALBICB 1Castres CAST 3Montauban MONT 6Clinique de l'Occitanie CDOCC 0L'Hôpital Joseph Ducuing HJD 0Clinique de l'Union CU 1Clinique Parc CP 1Hospital de Lavaur HL 1Clinique du Sidobre CS 1

TOT 178TOT - UNV 1 62

3 Millions

inhabitants

One thrombectomy

center

12 Stroke Units

20 hospitals

Maximum 10

patients /Year

Thrombectomy in France:

Should we open new centers ?

• Only very few

• Under the following Conditions :

– Must be > 150 Km or > 1h from the INR center

– Must do > 150 IV thrombolysis a year (80 MT)

• But we must improve patient transport

organization!

If a patient has a stroke 1H30 away from the

thrombectomy center

The time lost in transport is not all lost

During this time the INR/Anesthesiology

teams prepare everything for the MT

(30 to 60 min)

Things are done in parallel

So the need for a 1h 30 time to reach the INR

center should not be consider a 1h30 time

lost and patient lack of chance of good

outcomes but only 45min

60% of MT are done outside working hours

So the team has to come from home

(Interventionist, nurse, technician)

During working hours the angio-room is

usually occupied

Conclusion:

- Numbers of MT much smaller than for cardiology

- Need much less centers but with enough interventionists

( at least 4, better 6)

- With huge volumes (> 200/Y)

- Stroke dedicated angioroom

- Better transport organization

Thanks