time for stroke thrombectomy… conference 2016...• thrombectomy plus usual care (thrombolysis) vs...
TRANSCRIPT
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Time for Stroke Thrombectomy…
Jason Kendall Southmead Hospital
North Bristol NHS TrustSeptember 2016
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• Technology• Evidence• Clinical cases• Referral guideline
Thrombectomy for acute ischaemic stroke
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• Technology• Evidence• Clinical cases• Referral guideline
Thrombectomy for acute ischaemic stroke
“Do I need a thrombectomy…?”
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The technology… how does it work?
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Proximal occlusion… Recanalisation
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What is the evidence?
• Thrombectomy plus usual care (thrombolysis) vs usual care alone • CTA confirmation of proximal arterial occlusion in anterior cerebral circulation
+ESCAPESWIFT-PRIMEREVASCATEXTEND-IA
All published in NEJM, 2015
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TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
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TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
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TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
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TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
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TRIAL AGE NIHSS TIME RADIOLOGYMR CLEAN No age limit > 2 < 6 hrs No exclusion
ESCAPE No age limit “disabling stroke” < 12 hrs ASPECTS > 6Moderate to good collaterals on CTA
SWIFT - PRIME 18-80 “moderate to severe deficit” < 6 hrs ASPECTS > 6Target mismatch penumbra
REVASCAT 18-85 > 6 < 8 hrs ASPECTS > 7
EXTEND – IA No age limit Not specified < 6 hrs Evidence of salvageable tissue on CT perfusion; Ischaemic Core < 70 mls
TRIALS inclusion criteria
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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TRIAL AGE NIHSS IV t-PA Efficacy outcome (mRS 90 days)MR CLEAN(N=500)
66 17 89% OR 1.67 favourable mRS shift
ESCAPE(N=316)
71 17 73% Median mRS 2 vs 4 Functional independence 53% vs 29%
SWIFT – PRIME(N=196)
66 17 100% Median mRS 2 vs 3 Functional independence 60% vs 35%
REVASCAT(N=206)
66 17 78% OR 1.7 for favourable mRS shift
EXTEND – IA(N=70)
70 17 100% Median mRS 3 vs 1
TRIALS outcome
No safety concerns in any trial
What is the evidence?
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What is the evidence?
TRIALS outcome: pooled data (n=1287)
OR = 2.49 for reduced disability at 90 days
OR = 2.71 for functional independence (mRS = 0-2) at 90 days
NNT = 2.6 for reduced mRS by 1 point at 90 days
Effect consistent across wide range of age and stroke severity
Mean time to thrombolysis = 100 mins Mean time to thrombectomy = 285 mins The Lancet, April 2016
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TRIALS key message• Thrombectomy (in addition to standard care) is effective
and safe
Translation into clinical practice• Who?• When? • Where?
Trial inclusion criteria and logistics…
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Case 1• 40 year old male• Awoke at 0845am with RSW and speech
problems• Last seen well before bed at midnight • Wife called ambulance and taken to ED• Dysphasia with RSW• NIHSS 17
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Case 1: CT on arrival 09:24
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Case 1: CTA
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Case 1 angio
RecanalisationMCA occlusion
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Case 1 outcome• 24 hours NIHSS = 8 (17 at presentation)
• Home with ESD (after 2 weeks)• Walking• Moderate dysphasia
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Case 1 Discussion pointsHow much damage is acceptable on CTH before procedure
futile?MR CLEAN vs ESCAPE, SWIFT PRIME, REVASCAT
How important is the onset time?REVASCAT (<8hrs), ESCAPE (<12hrs) vs others (<6 hrs)
Would CTP have been useful?SWIFT PRIME, ESCAPE, EXTEND-IA
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Case 2• 90 year old female, previously living independently• Admitted with PE and new AF• Started rivaroxaban
• Dense left upper limb weakness and facial weakness whilst inpatient
• NIHSS 5
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Case 2: CT 60 minutes from symptom onset
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Case 2 CTA
…Discrepancy betweenNIHSS and proximal MCA
occlusion
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Right MCA occlusion
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Collateral flow from anterior cerebral artery…
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Collateral flow from anterior cerebral artery…
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Collateral flow from anterior cerebral artery…
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Collateral flow from anterior cerebral artery…
Initial contrast image… …several seconds later
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Recanalisation (120 mins post onset)Stent across thrombus
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Case 2: outcome
• NIHSS 2 at 24 hrs, neurologically independent
• Discharged to residential home
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Case 2 discussion pointsIs any age too old?
Inclusion criteria varied across trials16% > 80 years old in MR CLEAN
Is any NIHSS too low?Inclusion criteria varied across trialsOutcome for “minor stroke”?
Importance of CT angiography
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Case 3• 79 year old female• Background hypertension• Presented one hour after symptom onset to
DGH• NIHSS 18• Dense right sided weakness and dysphasia
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Case 3: initial CT at DGH
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Case 3• CTA confirmed proximal MCA occlusion• Thrombolysis and transfer• Transfer from DGH to SMD took 2 hours• On arrival dypshasia and weakness improving• NIHSS 10• Taken straight to angio suite for intervention
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Case 3 Angio
Recanalisation post iv tPAContinued to improve, discharged functionally independent NIHSS = 4
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Case 3 discussion points• Right decisions with right information early
CT and CTA at referring centre? Repeat imaging if situation substantially changes during transfer
• How to achieve rapid transfer?Robust referral pathwayTreat inter-hospital transfer as 999 call Consider helicopter transfer
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ED referral criteria for thrombectomy
Who? No upper age limitDemonstration of major vessel occlusion on CT angiogramNIHSS = 4 or higherTime from onset to intervention within 6 hours
When / Where? Monday – Friday, 8am – 4pm, Southmead Hospital
Action: (1) Commence IV thrombolysis (if no contra-indication)(2) Call stroke physician at Southmead to arrange transfer(3) Arrange transfer to Southmead ED
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Conclusions
• Thrombectomy is effective and safe• CT and CTA essential for patient selection• Longer time window for thrombectomy compared
with thrombolysis• Urgent referral and rapid transfer
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Time for Stroke Thrombectomy…
Jason Kendall Southmead Hospital
North Bristol NHS TrustSeptember 2016
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Basilar artery occlusion
Basil Fawlty…?
Before… …after
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National (IQR) NBT (IQR)
Onset to puncture (min) 211.5 (178.5-292.5) 168.5 (150-185)
Onset to end of procedure (min) 294.5 (234.5-360.5) 275 (216-285)
Puncture to deployment (min) 22 (15-31.5) 32 (20-35)
Puncture to end of procedure (min) 61.5 (41-85) 45 (31-108)
Clock start to puncture (min) 131.5 (89-181) 88.5 (65-92)
Clock start to deployment (min) 167.5 (111-208.5) 120 (112-124)
Clock start to end of procedure (min) 201.5 (152.5-254) 200 (120-200)
NBT experience30 cases from January – August 2016
SSNAP data:
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National (IQR) NBT (IQR)
Onset to puncture (min) 211.5 (178.5-292.5) 168.5 (150-185)
Onset to end of procedure (min) 294.5 (234.5-360.5) 275 (216-285)
Puncture to deployment (min) 22 (15-31.5) 32 (20-35)
Puncture to end of procedure (min) 61.5 (41-85) 45 (31-108)
Clock start to puncture (min) 131.5 (89-181) 88.5 (65-92)
Clock start to deployment (min) 167.5 (111-208.5) 120 (112-124)
Clock start to end of procedure (min) 201.5 (152.5-254) 200 (120-200)
NBT experience30 cases from January – August 2016
SSNAP data: