intervention in stroke-a new era

Vipul Gupta

Head, Neurointerventional SurgeryInterventional Neuroradiology

NEUROVASCULAR & STROKE CENTRE

Interventions in stroke:Interventions in stroke:A new eraA new era

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

Neurointervention Cath Lab- Biplane flat panel, 3D imaging, Road map, Dyna CT

NEUROINTERVENTION EVOLUTION…….

Neurointerventions…

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

Diagnosis- Imaging Interventional hardware Integrated approach

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

3 D

Balloon assisted coiling

Very small aneurysms

Stent assisted coiling

Flow diverters (stents)- no coils

Vasospasm- 15-25% morbidity and mortality

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

Embolization

Surgery

91%

9%

Good outcome

FND

Mortality

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

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

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

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

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

PENUMBRA, 2007MERCI, 2004

STENTREIVERS- SOLITAIRE (2012), TREVO…..

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

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

Clinical- Bleeding Seizures Neurological deficit Headaches Incidental

Cerebral Arteriovenous Cerebral 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

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