CURRENT STATUS OF STROKE INTERVENTIONS

DR. SUMIT KAMBLESENIOR RESIDENT, NEUROLOGYGMC, KOTA

MODERATOR -DR. BHARAT BHUSHANASSOCIATE PROFESSOR, NEUROLOGY

OVERVIEW1. Intervention in Ischemic stroke• Emergencya) Intravenous Fibrinolysisb) Endovascular Interventionsc) Decompressive Craniotomy• Electivea) Carotid Stentingb) Carotid Endarterectomy

2. Intervention in acute Hemorrhagic stroke

Intravenous Fibrinolysis

Recommendations• Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is

recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I; Level of Evidence A).

• In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. The door-to-needle should be within 60 minutes from hospital arrival (Class I; Level of Evidence A).

• Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (Class I; Level of Evidence B).

• Eligibility criteria for treatment in this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria:

a. Patients >80 years old, b. Taking oral anticoagulants regardless of INR,c. Baseline NIHSS score >25,d. Imaging evidence of ischemic injury involving more than one third of the

MCA territory,e. History of both stroke and diabetes mellitus.

• Intravenous rtPA is reasonable in patients whose blood pressure can be lowered safely (to below 185/110 mm Hg) with antihypertensive agents, with the physician assessing the stability of the blood pressure before starting intravenous rtPA (Class I; Level of Evidence B). 

• In patients undergoing fibrinolytic therapy, physicians should be aware of and prepared to emergently treat potential side effects, including bleeding complications and angioedema that may cause partial airway obstruction (Class I; Level of Evidence B).

• Intravenous rtPA is reasonable in patients with a seizure at the time of onset of stroke if evidence suggests that residual impairments are secondary to stroke and not a postictal phenomenon (Class IIa; Level of Evidence C).

• Effectiveness of sonothrombolysis for treatment of patients with acute stroke is not well established (Class IIb; Level of Evidence B). 

• Usefulness of intravenous administration of tenecteplase, reteplase, desmoteplase, urokinase, or other fibrinolytic agents and the intravenous administration of ancrod or other defibrinogenating agents is not well established, and they should only be used in the setting of a clinical trial (Class IIb; Level of Evidence B).

• Effectiveness of intravenous treatment with rtPA is not well established (Class IIb; Level of Evidence C) and requires further study for patients who can be treated in the time period of 3 to 4.5 hours after stroke but have 1 or more of the following exclusion criteria: (1) patients >80 years old, (2) those taking oral anticoagulants, even with INR ≤1.7, (3) those with a baseline NIHSS score >25, or (4) those with a history of both stroke and diabetes mellitus.

• Use of intravenous fibrinolysis in patients with conditions of mild stroke deficits, rapidly improving stroke symptoms, major surgery in the preceding 3 months, and recent myocardial infarction may be considered, and potential increased risk should be weighed against the anticipated benefits (Class IIb; Level of Evidence C).

• Intravenous administration of streptokinase for treatment of stroke is not recommended (Class III; Level of Evidence A).

• Use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arterial rtPA (Class III; Level of Evidence C).

Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who Could Be Treated With IV rtPA Within 3 Hours From Symptom Onset

Inclusion criteria

 Diagnosis of ischemic stroke causing measurable neurological deficit

 Onset of symptoms <3 hours before beginning treatment

 Aged ≥18 years

Exclusion criteria Significant head trauma or prior stroke in previous 3 months Symptoms suggest subarachnoid hemorrhage Arterial puncture at noncompressible site in previous 7 days History of previous intracranial hemorrhage Intracranial neoplasm, arteriovenous malformation, or aneurysm Recent intracranial or intraspinal surgery Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis, including but not limited to Platelet count <100 000/mm³ Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 seconds Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays) Blood glucose concentration <50 mg/dL (2.7 mmol/L)

 CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative exclusion criteria

 Recent experience suggests that under some circumstances—with careful consideration and weighting of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of IV rtPA administration carefully if any of these relative contraindications are present:

 Only minor or rapidly improving stroke symptoms (clearing spontaneously)

 Pregnancy

 Seizure at onset with postictal residual neurological impairments

 Major surgery or serious trauma within previous 14 days

 Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)

 Recent acute myocardial infarction (within previous 3 months)

Additional Inclusion and Exclusion Characteristics of Patients With Acute Ischemic Stroke Who Could Be Treated With IV rtPA Within 3 to 4.5 Hours From Symptom Onset

Inclusion criteria

 Diagnosis of ischemic stroke causing measurable neurological deficit

 Onset of symptoms within 3 to 4.5 hours before beginning treatment

Relative exclusion criteria

 Aged >80 years

 Severe stroke (NIHSS>25)

 Taking an oral anticoagulant regardless of INR

 History of both diabetes and prior ischemic stroke

• US FDA approved the use of intravenous rtPA in 1996 within 3 hours of stroke onset.

• FDA has not yet approved rtPA beyond 3 hours of stroke onset.

• Number needed to treat (NNT) to obtain one favorable outcome with alteplase :

NNT 4.5 for 0 to 90 minutesNNT 9.0 for 91 to 180 minutesNNT 14.1 for 181 to 270 minutesNNT 21.4 for 271 to 360 minutes

•  

TRIAL NO. OF PATIENTS/ TIME OUTCOME

NINDS Trial 1NINDS Trial 2

624 subjects within 3 hours of stroke onset 

Patients with minimal or no disability increased from 38% with placebo to 50% with tPA, a 12% absolute improvement

ECASS 1, ECASS 2, ATLANTIS A, ATLANTIS B

6 hours of stroke onset  Concordant with that found in the 2 NINDS trials for subset of patients within 3 hrs.

ECASS 3  821 patients within 4.5 hours Proportion of patients with minimal or no disability increased from 45% with placebo to 52% with tPA, a 7% absolute improvement.

IST-3  3035 patients within 6 hours from symptom onset 

Despite the early hazards, thrombolysis within 6 h improved functional outcome.

Other Fibrinolytic Agents

Streptokinase -

• Clinical trials of streptokinase were halted prematurely because of unacceptably high rates of hemorrhage

Tenecteplase • Modified tissue plasminogen activator with a longer half-life

and higher fibrin specificity than alteplase• Appears promising as an effective fibrinolytic• Not FDA approved

Desmoteplase

• Fibrinolytic agent isolated from vampire bat saliva. Two phase II trials of desmoteplase provided encouraging safety and potential efficacy data in penumbral imaging–selected patients 9 hours after stroke onset.

• Phase III studies are ongoing.

Transcranial Ultrasound Fibrinolysis Augmentation

• Ultrasound can be delivered to an acute cerebral arterial occlusion in several ways, including

(1) by a sonographic operator actively positioning a diagnostic Doppler or B-mode/color flow duplex imaging probe(2) by unfocused, low-frequency ultrasound that sonicates both the vessels and brain without imaging guidance(3) intra-arterial or intraclot delivery via catheter

CLOTBUST trial -  • 83% of patients achieved any recanalization (46% complete,

27% partial) with intravenous rtPA and TCD versus 50% (17% complete, 33% partial) with intravenous rtPA alone within 2 hours of treatment (P=0.001). The sICH rate was 3.8% in both groups.

Combination Intravenous Therapies

Acute Endovascular Interventions

Recommendations• Patients eligible for intravenous rtPA should receive intravenous

rtPA even if intra-arterial treatments are being considered (Class I; Level of Evidence A). 

• Intra-arterial fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA who are not otherwise candidates for intravenous rtPA (Class I; Level of Evidence B).

• As with intravenous fibrinolytic therapy, reduced time from symptom onset to reperfusion with intra-arterial therapies is highly correlated with better clinical outcomes, and all efforts must be undertaken to minimize delays to definitive therapy (Class I; Level of Evidence B).

• Intra-arterial treatment requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified interventionalists. An emphasis on expeditious assessment and treatment should be made. Facilities are encouraged to define criteria that can be used to credential individuals who can perform intra-arterial revascularization procedures. Outcomes on all patients should be tracked (Class I; Level of Evidence C). 

• When mechanical thrombectomy is pursued, stent retrievers such as Solitaire FR and Trevo are generally preferred to coil retrievers such as Merci (Class I; Level of Evidence A). The relative effectiveness of the Penumbra System versus stent retrievers is not yet characterized. 

• The Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients (Class IIa; Level of Evidence B).

• Intra-arterial fibrinolysis or mechanical thrombectomy is reasonable in patients who have contraindications to the use of intravenous fibrinolysis (Class IIa; Level of Evidence C). 

• Rescue intra-arterial fibrinolysis or mechanical thrombectomy may be reasonable approaches to recanalization in patients with large-artery occlusion who have not responded to intravenous fibrinolysis. Additional randomized trial data are needed (Class IIb; Level of Evidence B).

• Usefulness of mechanical thrombectomy devices other than the Merci retriever, the Penumbra System, Solitaire FR, and Trevo is not well established (Class IIb; Level of Evidence C).

• Usefulness of emergent intracranial angioplasty and/or stenting is not well established. These procedures should be used in the setting of clinical trials (Class IIb; Level of Evidence C). 

• Usefulness of emergent angioplasty and/or stenting of the extracranial carotid or vertebral arteries in unselected patients is not well established (Class IIb; Level of Evidence C). Use of these techniques may be considered in certain circumstances, such as in the treatment of acute ischemic stroke resulting from cervical atherosclerosis or dissection (Class IIb; Level of Evidence C).

Intra-arterial Fibrinolysis

PROACT II – • To  test the effectiveness of intra-arterial fibrinolysis using r-

pro-UK to treat MCA (M1 or M2) occlusions within 6 hours of stroke symptom onset.

• 40% of the 121 patients treated with r-pro-UK and 25% of the 59 control patients had an mRS score of 0 to 2 at 90 days (P=0.04). MCA recanalization was achieved in 66% of the r-pro-UK arm and 18% of the control group (P=0.001). sICH occurred in 10% of patients treated with r-pro-UK and in 2% of the control group (P=0.06).

• Use of intra-arterial fibrinolysis for occlusions in additional locations, such as the basilar artery and intracranial carotid artery, is based primarily on consensus and case series.

• Meta-analysis of multiple case series comparing intravenous with intra-arterial fibrinolysis for acute vertebrobasilar stroke in 422 patients showed marginally better recanalization rates with intra-arterial therapy (65% versus 53%; P=0.5), good neurological outcomes in 22% to 24% of patients, but no clear difference in efficacy between the 2 modalities

• Results of PROACT-II were considered insufficient to grant FDA approval

• Intra-arterial fibrinolysis is a consideration for patients ineligible for intravenous rtPA

a. Treatment within 4.5 to 6 hours;b. Recent history of a major surgical procedure

Mechanical Clot Disruption/Extraction

• Primary reperfusion strategy and in conjunction with pharmacological fibrinolysis for achieving recanalization in patients with acute ischemic stroke.

• Patients who are ineligible for treatment with IV-rtPA or who fail IV-rtPA therapy are candidates for treatment.

• Currently 4 devices cleared by the FDA for recanalization of arterial occlusion in patients with ischemic stroke.

a. Merci Retrieval System b. Penumbra Systemc. Solitaire Flow Restoration Deviced. Trevo Retriever 

• Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial - designed to test the safety and efficacy of the Merci clot retrieval device to restore the patency of intracranial arteries within the first 8 hours of an acute stroke in 141 patients.

•  Recanalization was significantly higher (48% vs 18%)

• Multi-MERCI trial• Pivotal Penumbra trial• SWIFT study

Thrombectomy animation.mp4

Acute Angioplasty and Stenting

Intracranial Acute Angioplasty and Stenting• Urgent angioplasty with adjunctive stent deployment is being

used to restore antegrade flow, with or without fibrinolysis or clot extraction.

• Current data, which are limited to case series, suggest high (80%–90%) recanalization rates and reasonable safety

 Stent-Assisted Recanalization in Acute Ischemic Stroke (SARIS) study • 20 patients ineligible for or not responsive to intravenous rtPA,

partial or complete recanalization was achieved in all patients.

Extracranial Acute Angioplasty and Stenting• Predominantly performed for stroke prevention rather than

acute stroke treatment.

• Used on an emergency basis in the setting of acute stroke for 2 situations in particular:

• A. Primary cause of the stroke is attenuation or cessation of flow in the extracranial carotid or vertebral artery

• B. When catheter access to a culprit intracranial thrombus is impeded by severe stenosis of the extracranial carotid.

• No completed prospective, randomized controlled trials demonstrating relative efficacy and safety

• Nedeltchev et al described angioplasty and stenting of the internal carotid artery in conjunction with intra-arterial fibrinolysis in 25 patients who had acute carotid artery occlusion that caused MCA territory ischemic stroke and compared them with a group of 31 medically treated patients. Favorable outcomes were more frequent (56% versus 26%) 

Decompressive craniectomy in Ischemic Stroke

• 1. In patients <60 years of age with unilateral MCA infarctions that deteriorate neurologically within 48 hours despite medical therapy, decompressive craniectomy with dural expansion is effective. The effect of later decompression is not known, but it should be strongly considered (Class I; Level of Evidence B).

• 2. Although the optimal trigger for decompressive craniectomy is unknown, it is reasonable to use a decrease in level of consciousness and its attribution to brain swelling as selection criteria (Class IIa; Level of Evidence A).

• 3. Efficacy of decompressive craniectomy in patients >60 years of age and the optimal timing of surgery are uncertain (Class IIb; Level of Evidence C).

• 4. Suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarctions who deteriorate neurologically despite maximal medical therapy (Class I; Level of Evidence B).

• Three prospective, randomized trials studied patients with supratentorial infarctions treated with decompressive craniectomy, usually within 48 hours of stroke onset.

1. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery [DESTINY],

2. Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction [DECIMAL], and

3. Hemicraniectomy After Middle Cerebral Artery Infarction With Life-threatening Edema Trial [HAMLET])

• Showed reduced mortality with hemicraniectomy compared with medical management (22% versus 71% mortality, pooled analysis) in patients <60 years of age.

• No individual study showed an improvement in percentage of survivors with good outcomes (mRS score, 0–3), although this improvement (43% versus 21%) was noted in a pooled analysis.

Older patients would experience a similar effect ?

• Randomized study of 47 patients included patients 18 to 80 years of age, with 18 patients 61 to 70 years and 11 patients 71 to 80 years of age.

• Significant benefit of surgery was found in this small subset of patients >60 years of age (1-year mortality reduced from 69.6% to 16.7%) and on poor outcome (1-year mRS score >4 reduced from 100% to 37.5%).

• DESTINY 2 - include patients 62 to 82 years of age.

Surgical Treatment of ICHRecommendations• 1. Patients with cerebellar hemorrhage who are deteriorating

neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B).

• Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended (Class III; Level of Evidence C).

• 2. For most patients with supratentorial ICH, usefulness of surgery is not well established (Class IIb; Level of Evidence A). Specific exceptions are outlined below.

• 3. Policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacuation when patients deteriorate (Class IIb; Level of Evidence A).

• 4. Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Class IIb; Level of Evidence C).

• For patients presenting with lobar clots >30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be consideration (Class IIb; Level of Evidence: B).

• 5. DC with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management (Class IIb; Level of Evidence C).

• 6. Effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Class IIb; Level of Evidence B).

Intraventricular Hemorrhage

• IVH in association with ICH increased the risk of death from 20% without to 51% with IVH.

• 1. Although intraventricular administration of rtPA in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment are uncertain (Class IIb; Level of Evidence B).

• 2. Efficacy of endoscopic treatment of IVH is uncertain (Class IIb; Level of Evidence B).

• Largest trial of intraventricular fibrinolysis - CLEAR-IVH trial• Patients treated with rtPA had significantly lower intracranial

pressures, fewer VC obstructions that required replacement, and nonsignificantly shorter duration of VC requirement.

• Symptomatic rebleeding in 9 rtPA patients - (12%)• Median 30-day modified Rankin scale score was 5 in both

groups, and mortality was 19%, with no significant difference between placebo and rtPA.

• Phase 3 randomized CLEAR III trial.

Craniotomy for Supratentorial Hemorrhage

STICH trial- • 1033 patients were randomized to early surgery (<24 hours of

randomization) or initial conservative treatment.• No overall statistically significant difference in mortality or

functional outcome between treatment groups.• Subgroup analysis suggested that patients with lobar

hemorrhages within 1 cm of the cortical surface might benefit from surgery.

STICH II trial• Early surgery would be beneficial for conscious patients with

superficial lobar hemorrhage of 10 to 100 mm3 within 1 cm of cortical surface and without IVH and who were admitted within 48 hours of ictus.

• Forty-one percent of patients in the early surgery group had a favorable outcome compared with 38% in the medical arm;

• Difference was not statistically significant.

Craniotomy for Posterior Fossa Hemorrhage

• Because of the narrow confines of the posterior fossa, deterioration can occur quickly in cerebellar hemorrhage caused by obstructive hydrocephalus or local mass effect on the brainstem.

• Several nonrandomized studies have suggested that patients with cerebellar hemorrhages >3 cm in diameter or patients in whom cerebellar hemorrhage is associated with brainstem compression or hydrocephalus have better outcomes with surgical decompression.

Minimally Invasive Surgical Evacuation of ICH

• Randomized study of 465 patients compared needle aspiration of basal ganglia hemorrhages (25–40 mm3) to medical management alone.

• Although there was no significant impact on mortality, 3-month neurological outcome was better in the aspiration group.

• Minimally Invasive Surgery Plus Recombinant Tissue-Type Plasminogen Activator for ICH Evacuation Trial II (MISTIE II) aimed to determine the safety of minimally invasive surgery plus rtPA in the setting of ICH.

• Demonstrated a significant reduction in perihematomal edema in the hematoma evacuation group with a trend toward improved outcomes.

• A randomized phase 3 clinical trial of minimally invasive hematoma evacuation (MISTIE III) is currently in progress.

Preventive Endovascular Stroke Treatment Asymptomatic Carotid Stenosis

• 1. Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin. Patients should also be screened for other treatable risk factors for stroke, and appropriate medical therapies and lifestyle changes should be instituted (Class I; Level of Evidence C).

• 2. In patients who are to undergo CEA, aspirin is recommended perioperatively and postoperatively unless contraindicated (Class I; Level of Evidence C).

• 3. It is reasonable to consider performing CEA in asymptomatic patients who have >70% stenosis of internal carotid artery if risk of perioperative stroke, MI, and death is low (<3%). However, its effectiveness compared with contemporary best medical management alone is not well established (Class IIa; Level of Evidence A).

• 4. It is reasonable to repeat duplex ultrasonography annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to therapeutic interventions in patients with atherosclerotic stenosis >50% (Class IIa; Level of Evidence C)

• 5. Prophylactic CAS might be considered in highly selected patients with asymptomatic carotid stenosis (minimum, 60% by angiography, 70% by validated Doppler ultrasound), but its effectiveness compared with medical therapy alone in this situation is not well established (Class IIb; Level of Evidence B)

• 6. In asymptomatic patients at high risk of complications for carotid revascularization by either CEA or CAS, the effectiveness of revascularization versus medical therapy alone is not well established (Class IIb; Level of Evidence B).

• 7. Screening low-risk populations for asymptomatic carotid artery stenosis is not recommended (Class III; Level of Evidence C).

Symptomatic Carotid Stenosis:Recommendations

• 1. For patients with a TIA or ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis as documented by noninvasive imaging, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6% (Class I; Level of Evidence A).

• 2. For patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid stenosis as documented by catheter-based imaging or noninvasive imaging with corroboration (eg, magnetic resonance angiogram or computed tomography angiogram), CEA is recommended depending on patient-specific factors, such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6%(Class I; Level of Evidence B)

• 3. When the degree of stenosis is < 50%, CEA and CAS are not recommended (Class III; Level of Evidence A).

• 4. When revascularization is indicated for patients with TIA or minor, nondisabling stroke, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery if there are no contraindications to early revascularization (Class IIa; Level of Evidence B).

• 5. CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the ICA is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is < 6% (Class IIa; Level of Evidence B).

• 6. It is reasonable to consider patient age in choosing between CAS and CEA. For older patients (ie, older than ≈70 years), CEA may be associated with improved outcome compared with CAS, particularly when arterial anatomy is unfavorable for endovascular intervention. For younger patients, CAS is equivalent to CEA in terms of risk for periprocedural complications (ie, stroke, MI, or death) and long-term risk for ipsilateral stroke (Class IIa; Level of Evidence B).

• 7. Among patients with symptomatic severe stenosis (>70%) in whom anatomic or medical conditions are present that greatly increase the risk for surgery or when other specific circumstances exist such as radiation-induced stenosis or restenosis after CEA, CAS is reasonable (Class IIa; Level of Evidence B).

• 8. CAS and CEA in the above settings should be performed by operators with established periprocedural stroke and mortality rates of < 6% for symptomatic patients, similar to that observed in trials comparing CEA to medical therapy and more recent observational studies (Class I; Level of Evidence B).

• 9. Routine, long-term follow-up imaging of the extracranial carotid circulation with carotid duplex ultrasonography is not recommended (Class III; Level of Evidence B). (New recommendation)

• 10. For patients with a recent (within 6 months) TIA or ischemic stroke ipsilateral to a stenosis or occlusion of the middle cerebral or carotid artery, EC/ IC bypass surgery is not recommended (Class III; Level of Evidence A).

• 11. For patients with recurrent or progressive ischemic symptoms ipsilateral to a stenosis or occlusion of a distal (surgically inaccessible) carotid artery, or occlusion of a midcervical carotid artery after institution of optimal medical therapy, the usefulness of EC/IC bypass is considered investigational (Class IIb; Level of Evidence C).

• 12. Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with carotid artery stenosis and a TIA or stroke, as outlined elsewhere in this guideline (Class I; Level of Evidence A).

carotid stenting.mp4

Carotid Endarterectomy.mp4

THANK YOU

REFERENCES

• Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015

• Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling 2014

• AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke 2013

• Thrombolytic Therapy in Stroke  Nov 2016 Medscape• Uptodate.com