cardiologist’s point of view · background of wus • wake-up stroke is a condition, affecting...
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How late is too late to recanalizecarotid and intracranial thrombosis
after stroke? Late Stroke interventions. Cardiologist’s point of view
Ivo Petrov, MD, PhD, FESC, FACC
Head Cardiology/angiology Dpt
Acibademm City Clinic, Sofia, Bulgaria
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DISCLOSURE STATEMENTOF FINANCIAL INTEREST
I, Ivo Petrov, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived
as a real or apparent conflict of interest in the context of the subject
of this presentation.
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Endovascular experience after 6 years of work:
• 13800 endovascular cases (“Head to toe”):
– CTO and Left main Coronary interventions
– EVAR/TEVAR
– TAVR
– Intracranial thrombus retrieval in stroke
– CAS and intracranial EVI (>900)
– Radial approach for complex peripheral cases
– Complex venous interventions (including May-Thurner, CCSVI)
– Renal denervation
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Proportion: Stroke mortality to general mortality in Bulgaria 2013
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1. Worldwide Epidemiology of Atrial Fibrillation: A
Global Burden of Disease 2010 Study - Sumeet S. 2.
ATRIAL FIBRILLATION – THE NEW EPIDEMIC Tch.
Shalganov National Heart Hospital – Sofia
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1. Worldwide Epidemiology of Atrial Fibrillation: A
Global Burden of Disease 2010 Study - Sumeet S. 2.
ATRIAL FIBRILLATION – THE NEW EPIDEMIC Tch.
Shalganov National Heart Hospital – Sofia
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Huge LA
mixoma in a
patient with
AIS
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Mobile LV
thrombus in a
patient with
severe
dilative
cardiomyopathy
and AIS
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Different modalities in catheter based stroke tharapy
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Within 6 hrs of symptoms onset
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EVT of AIS beyond 6 hours
S. Vidale et al. Mechanical…J Clin Neurol 2018;14(3):407-412
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Stroke EVT beyond 6 hours
Functional independence at 90 days from stroke onset, mRss= 0,1,2
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(Stroke. 2018;49:e46–e99. DOI: 10.1161/STR.0000000000000158.)
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Endovascular treatment of stroke
Stroke. 2018;49:e46–e99. DOI: 10.1161/STR.0000000000000158.
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Imaging based decision for EVT of stroke
DAWN used a stratification by age and National Institutes of
Health Stroke Scale score leading to differing maximum infarct
core cutoff volumes measured by a specific imaging software in
an automated fashion (>80 years core up to 20 mL, 1.8 (ratio)
and 15 mL (penumbra volume), again measured by a specific
imaging software in an automated fashion. The median infarct
core volume was 8 and 10 mL in DAWN and DEFUSE 3,
respectively. More than half of all the trial subjects presented
with wake up strokes in both trials.
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Multiple strategies have been adopted, including
clinical-core mismatch, perfusion-imaging
mismatch or NCCT ASPECTS to estimate infarct
core, and mCTA to assess collateral status. This
range of potential selection tools highlights current
uncertainty about the best inclusion criteria.
Motyer R, et al. J NeuroIntervent Surg 2018;0:1–4. doi:10.1136/neurintsurg-2017-013575
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Motyer R, et al. J NeuroIntervent Surg 2018;0:1–4. doi:10.1136/neurintsurg-2017-013575
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Acute Ischemic Stroke Care Today . Time is BRAIN
Symptoms Primary Stroke Center
EMSCall
Stroke CenterEMS IV Lytic
Clot retrievalAngiogram
Stroke Unit
Advanced Imaging
Imaging
Telemedicine
INR Cath Lab
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Acute Ischemic Stroke Care Today . Time is BRAIN
Symptoms Call
EMS IV Lytic
Clot retrievalAngiogram
Stroke Unit
Advanced Imaging
Imaging
Telemedicine
INR Cath Lab
Direct transfer from
EMS to CathLab
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Bulgaria. pPCI coverage
After ESC “Stent for life” initiative implementation
2017
Stent for life experience
STEMI mortality reduction:
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Interventional recanalization of intracranial arteries. City Clinic experience 2016-2018 (n=18)
EVT Stroke team
4 neurolgists
2 neuroimaging specialists
3 interventional cardioangiologists
12 anaestesiologists
2 cathlabs/24 hrs
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First ever mechanical recanalization of stroke related artery 2001 in Bulgaria. Performed by a cardiologist.
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Clinical case 1. Wake-up stroke
Variables/ Parameters Pt No 1, VAge (years) / Gender 54 y/o, manNIHSS Pretreatment 15Initial mRS 5Initial CT / MRI imaging CT, CT-AAcute occlusion site Left extracranial ICAStroke etiology Cardioembolic
Wake-up Stroke2nd Postooperative day
Patient Diseases IHD, Triple Vessel Cardiac Disease, STEMI, АH 3, DM 2 TYPE, АCB х 4
Average time from onset to groin puncture (h) Unknown (<6 h)
Average time to TICI 2b/3 recanalization (min)
Final TICI result TICI 3NIHSS at discharge (* dif) 5 (12 DAY)mRS on discharge 3mRS, 90 day 1Device related complications NoDevice tips and tricksSymptomatic ICH NoMortality No
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Background of WUS
• Wake-up stroke is a condition, affecting ≈ 8-25% of patients with stroke.• It is a distinct but underprivileged subgroup of patients with stroke.• a challenge to acute stroke treatment• Since the time window is unknown, the majority of patients with WUS are
excluded from reperfusion treatment with IV thrombolysis or EVT.• However, a relevant number of these patients might benefit from reperfusion
treatment. • There are some brain imaging concepts guiding the reperfusion treatment in
patients with unknown time of symptom onset.• Thrombolysis in selected patients with WUIS is feasible, and its outcomes are
comparable with those thrombolysed with 0 to 4.5 hours. • There are limited data on the risks and benefits of reperfusion therapies for
WUS.
Treatment Concepts for Wake-Up Stroke and Stroke With Unknown Time of Symptom Onset. G.Thomalla, C. Gerloff. Stroke. 2015;46:9 2707-2713Reperfusion Therapies for Wake-Up Stroke. Systematic Review. Deborah Buck, Lisa C. Shaw, Christopher I. Price, Gary A. Ford, B Chir. Stroke. 2014;45:6 1869-1875.Wake-up stroke: clinical characteristics, imaging findings, and treatment option – an update. D. Leander Rimmele, G.Thomalla. Frontiers in Neurology. March 2014; Vol 5; Article 35: 1-7.
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Neuroimaging is crucial to determine the candidates
for EVT in late comers and WUS
• In large multicenter studies (PRE-FLAIR:PRE-dictive value of FLAIR and DWI for the identification of acute ischemic stroke patients 3 and 4.5 h of symptom onset–a multicenter study including 643 patients (Lancet Neurol (2011) 10:978–86.).
• The specificity of the DWI-FLAIR-mismatch to identify patients within the time frame of 4.5h was in this study 0.81 and the PPV 0.87.
D. Leander Rimmele, G.Thomalla. Frontiers in Neurology. 2014; Vol 5;
Art35: 1-7.
DWI-FLAIR-mismatch was shown to identify patients
within 3–4.5 h with high specificity and positive predicted
value (PPV);
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Interventional EV Procedure: ADAPT
• “Carotid T-occlusion”
• Imitating occlusion of
the carotid artery
• In fact is cause by an
embolus sitting on the
bifurcation
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Interventional EV Procedure: ADAPT
• A selective cannulation of LCCA with 6 Fr catheter Benchmark was performed, followed by introduction of ACE catheter in proximal part of ICA.
• Over a 0,014’’ wire catheter Neuron 5MAX as placed proximal to the occlusion.
• Selective thromboaspiration was performed with Penumbra aspiration system.
• Post aspirational angiography reveals no residual thrombosis with excellent angiographic result, TICI score 3.
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Interventional EV Procedure: ADAPT
• After 3 aspirational
passes with the 5
MAX
• Post aspirational
angiography
reveals no residual
thrombosis with
excellent
angiographic
result, TICI score
3.
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Outcome
• The patient was discharged on the 12th post
procedural day;
• The neurologic examination on the day the
discharge reveals no motor deficit only persisting
sensory aphasia. NIHSS = 5; mRS = 3
• 90 day mRS = 1
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90 days
MRA
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90 days
MRA
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Case II
Gender: male, 66y., late acute stroke comer (Aphasic and right side hemiplegic since 25
hours, Systemic thrombolysis resulted inefective)
NIHHSS= 19 (Major stroke)Concomitant disease:
- 2 vessel coronary disease, history of LAD PCI, 6 y. before
- Arterial hypertension II grade, dyslipidemia, smoker
Vascular access: Right femoral artery, Shuttle sheath 6F
Target carotid artery: LICA- nearly full thrombosis
Primary distal protection system: Spider 5.0 after recanalization with coronary microcatheter and
distal confirmation
Implanted stent:
After predilatation Tapered X-Act 8-6/40mm.
Postdilatation:
Double protection (thrombus containing lesion) + balloon
Paladin 5.0/20 mm.
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LICA near occlusion (subacute thrombosis)
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.014 Runthrough Hypercoat supported by FineCrossmicrocatheter
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“Double filter” protection (thrombus containing lesion)postdilation Paladin (Contego) 5.0/20mm:
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TICI-3 flow restored
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TICI-III flow with normalized
parenchymal phase
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Clinical course
• Speech restored immediately after intervention
• NIHSS= 4 at 30 days after (mild right hemiparesis and hemihypoestesia)
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17years girl 3 days after open heart ASD surgical closure. Woke up with signs of stroke
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Conclusions
• In AIS the transformation of Penumbra to core infarct is dependent on time and collaterals
• The clinical outcome is directly dependent on recanalization success• Innovations in catheter based mechanical thrombectomy lead to
significant improvement in recanalization rate• In the updated guidelines (2018/2019) high level of indication for EVT
of stroke is extended to patients with witnessed onset of symptoms within 6 to 24 hours and wake up stroke, meeting the necessary neuroimaging criteria for core/to ischemic tissue mismatch
• Strict regulations establishing multidisciplinary collaboration are crucial for the success of a local stroke/endovascular program
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The most frequent cause for ischemic stroke is:
А. Atherosclerotic obstruction of carotid artery
B. Cardio-embolism
C. Aortic dissection
D. Hypertensive attack
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Which statement is true:
А. Initial systemic thrombolysis is a contraindication for endovascular thrombectomy in patients with ischemic stroke
B. Systemic thrombolysis is likely to improve the final result of endovascular thrombectomy if undertaken within 6 hours of symptoms onset
C. Catheter based thrombectomy is a golden standard for treatment of patients with ischemic stroke between 6 and 24 hours after symptoms onsetin case of positive neuroimaging criteria for cor to penumbra difference
D. Catheter based thrombectomy is a golden standard for treatment of all patients with ischemic stroke between 6 and 24 hours after symptoms onset
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Which of the trials listed bellow did not enroll acute ischemic stroke patients beyond 6 hours of
symptom onset?
• DEFUSE-3
• DAWN
• MR CLEAN
• REVASCAT