Download - 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
STROKE AND NEUROVASCULAR INTERVENTION FOUNDATION
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