evidence and potential implications of the 6 24h evt treatment … · stroke treatment: exciting...
TRANSCRIPT
![Page 1: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/1.jpg)
Evidence and potential implications of the 6 – 24h EVT treatment
window for AIS
Vitor Mendes Pereira MD MSc
Divisions of Neuroradiology and Neurosurgery
Toronto Western Hospital - University Health Network
Medical Imaging and Surgery departments - University of Toronto, Canada
![Page 2: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/2.jpg)
Disclosure Statement of Financial Interest
• Global PI of STAR trial
• Interventional Principal Investigator of SWIFT-PRIME Trial (Medtronic sponsored trial)
• North America Principal Investigator of SWIFT-DIRECT Trial (Medtronic sponsored trial)
• Consultant for Penumbra (PROMISE trial), and Stryker (DAWN trial, TREVO registry), Neurovasc Med (start up), Marblehead (start up)
Affiliation/Financial Relationship
![Page 3: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/3.jpg)
2015-2018: Highly effective reperfusion therapies
![Page 4: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/4.jpg)
HERMES collaboration
• 5 trials published in early 2015– MRCLEAN– ESCAPE– SWIFTPRIME– EXTEND IA– REVASCAT
• All supported endovascular thrombectomy as a definitive treatment for anterior circulation, large vessel occlusive ischemic stroke
• Pooled analyses of individual patient data will allow:– Greater precision– Analysis of subgroups
HERMES Collaboration
![Page 5: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/5.jpg)
Methods
• A literature review confirmed that 5 major trials examining modern endovascular stroke treatment were published at the time of analysis
• A mixed effects model, with study as a random variable was used to assess the treatment effect across the 5 studies
• Sub-groups of interest were age, sex, occlusion location, ASPECTS score, treatment with alteplase and time from randomization
![Page 6: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/6.jpg)
Baseline Characteristics(N=1287)
![Page 7: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/7.jpg)
Baseline Characteristics
![Page 8: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/8.jpg)
Overall Treatment EffectNNT = 2.6
2018-06-20 HERMES Collaboration 9
![Page 9: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/9.jpg)
Overall Treatment EffectNNT = 2.6
2018-06-20 HERMES Collaboration 10
![Page 10: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/10.jpg)
Treatment effect by agemRS 0-2 at 90 days
2018-06-20 HERMES Collaboration 11
![Page 11: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/11.jpg)
Treatment effect is strong across occlusion sites (pint=0.35)
2018-06-20 HERMES Collaboration 12
![Page 12: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/12.jpg)
HERMES Collaboration 14
![Page 13: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/13.jpg)
HERMES Collaboration 15
![Page 14: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/14.jpg)
AHA Guidelines 2015
![Page 15: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/15.jpg)
Canadian best practices 2015
Casaubon et al
![Page 16: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/16.jpg)
Canadian best practices 2015
Casaubon et al
![Page 17: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/17.jpg)
Case Discussion
• 62y, F
• Time from stroke onset – 9h
• NIHSS – 18
• Afib
![Page 18: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/18.jpg)
Baseline CT – Good ASPECTS (9-10)
![Page 19: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/19.jpg)
Male Patient - Perfusion CTCT Perfusion – Small core (20cc)
![Page 20: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/20.jpg)
What would you do?
• Next EVT hospital was 2h away
![Page 21: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/21.jpg)
What would you do?
• Next EVT hospital was 2h away
• Year 2013
![Page 22: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/22.jpg)
What would you do?
• Next EVT hospital was 2h away
• Year 2013
• Recommended transfer to an EVT center
![Page 23: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/23.jpg)
What would you do?
• Next EVT hospital was 2h away
• Year 2013
• Recommended transfer to an EVT center
• Arrival at EVT center 13 hours after stroke onset
![Page 24: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/24.jpg)
What would you do?
Mechanical Thrombectomy
![Page 25: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/25.jpg)
Initial Angiogram
![Page 26: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/26.jpg)
Microcatheter positioning
![Page 27: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/27.jpg)
Mechanical Thrombectomy
1/4, 1/3
![Page 28: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/28.jpg)
Guiding Balloon inflated
Solitaire device
Mechanical Thrombectomy
![Page 29: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/29.jpg)
Guiding Balloon inflated
Solitaire device
Mechanical Thrombectomy
![Page 30: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/30.jpg)
Solitaire device
Guiding Balloon inflated
Mechanical Thrombectomy
![Page 31: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/31.jpg)
Guiding Balloon inflated
Solitaire device
Mechanical Thrombectomy
![Page 32: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/32.jpg)
Guiding Balloon inflated
Solitaire device
Mechanical Thrombectomy
![Page 33: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/33.jpg)
Guiding Balloon inflated
Solitaire device
Mechanical Thrombectomy
![Page 34: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/34.jpg)
Final Angiography: Complete reperfusion
![Page 35: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/35.jpg)
Follow-up imaging
• Procedure time - 17min (1 operator)
• Conscious sedation
• NIHSS - 1 at 5 days
• mRS 0 at 90 days
![Page 36: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/36.jpg)
Late presenter
• How to explain apparent larger treatment benefits with later treatment?
![Page 37: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/37.jpg)
Ischemic Penumbra
Penumbra
Infarction
![Page 38: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/38.jpg)
Time is an independent outcome predictor
STAR study STAR/SWIFT study
Stroke 2014, Ann Neurol 2015
![Page 39: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/39.jpg)
Late presenter
• How to explain apparent larger treatment benefits with later treatment?
– Strokes evolve, and it’s mainly dependent on collaterals1
1: Albers et al, Late Window Paradox, Stroke. 2018;
![Page 40: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/40.jpg)
![Page 41: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/41.jpg)
![Page 42: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/42.jpg)
Malignant profile:• Poor Collaterals• Genetics of
stroke• Risk factors
![Page 43: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/43.jpg)
Late presenter
• How to explain apparent larger treatment benefits with later treatment?
– Strokes evolve, and it’s mainly dependent on collaterals1
• DEFUSE 2 showed that it usually takes 3 days for max. infarct size in non-reperfused patients
1: Albers et al, Late Window Paradox, Stroke. 2018;
![Page 44: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/44.jpg)
Time is an independent outcome predictor?
DEFUSE 2, Neurol 2015
Response to reperfusion is not time dependent in patients with salvageable tissue
![Page 45: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/45.jpg)
Late presenter
• How to explain apparent larger treatment benefits with later treatment?
– Strokes evolve, and it’s mainly dependent on collaterals1
• DEFUSE 2 showed that it usually takes 3 days for max. infarct size in non-reperfused patients
• These collaterals will eventually fail and infarct volumes will eventually increase
1: Albers et al, Late Window Paradox, Stroke. 2018;
![Page 46: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/46.jpg)
Time is an independent outcome predictor?
STAR/SWIFT study
Stroke 2014, Ann Neurol 2015
ESCAPE
Early trials had low restrictions on core sizeOn inclusion
![Page 47: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/47.jpg)
Time is an independent outcome predictor?
DEFUSE 2, Neurol 2015
Response to reperfusion is not time dependent in patients with salvageable tissue
![Page 48: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/48.jpg)
Late presenter
• How to explain apparent larger treatment benefits with later treatment?
– Strokes evolve, and it’s mainly dependent on collaterals1
• DEFUSE 2 showed that it usually takes 3 days for max. infarct size in non-reperfused patients
• These collaterals will eventually fail and infarct volumes will eventually increase
– Fast x Slow Progressors!
1: Albers et al, Late Window Paradox, Stroke. 2018;
![Page 49: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/49.jpg)
![Page 50: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/50.jpg)
Late Therapeutic Window Trials
• DAWN
• DEFUSE 3
![Page 51: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/51.jpg)
Late therapeutic window paradox?
![Page 52: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/52.jpg)
DAWN trial
![Page 53: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/53.jpg)
DAWN trial
![Page 54: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/54.jpg)
DAWN trial
![Page 55: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/55.jpg)
DAWN trial
![Page 56: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/56.jpg)
DAWN trial
![Page 57: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/57.jpg)
Trial Design
• 26 centres worldwide
• At least 40 thrombectomy procedures per centre per year
• Trevo device
• Stenting of ICA not permitted
• Angioplasty of ICA was permitted
![Page 58: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/58.jpg)
DAWN trial
![Page 59: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/59.jpg)
![Page 60: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/60.jpg)
Results
![Page 61: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/61.jpg)
Results
![Page 62: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/62.jpg)
Miscellanous
• Median baseline core by RAPID (IQR)– 7.6mls (2 – 18) thrombectomy group
– 8.9mls (3 – 18) control group
• Time from qualifying imaging to arterial puncture: 57 min (36-84)
• Time from randomisation to arterial puncture: 16 min (9-29)
• Time LSW to revascularisation: 13.6 hours (11.3-18.0)
![Page 63: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/63.jpg)
![Page 64: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/64.jpg)
mRs of ≤2 @ 90 days49% in thrombectomy group v 13% in control group
![Page 65: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/65.jpg)
DAWN trial
![Page 66: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/66.jpg)
![Page 67: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/67.jpg)
![Page 68: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/68.jpg)
![Page 69: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/69.jpg)
![Page 70: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/70.jpg)
The DAWN of a new era
![Page 71: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/71.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 72: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/72.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 73: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/73.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 74: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/74.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 75: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/75.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 76: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/76.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 77: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/77.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 78: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/78.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 79: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/79.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 80: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/80.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 81: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/81.jpg)
Defuse 3 Trial
Albers, NEJM 2018
![Page 82: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/82.jpg)
Defuse 3 Trial
![Page 83: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/83.jpg)
Defuse 3 Trial
![Page 84: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/84.jpg)
DAWN and DEFUSE 3 in practice
![Page 85: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/85.jpg)
DAWN and DEFUSE 3 in practice
Time window
• 0 - 6h. Level 1A
• 6 – 16H. Level 1A. DAWN and DEFUSE 3
• 16 – 24h. Only DAWN Patients. Level 2A B-R.
![Page 86: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/86.jpg)
DAWN and DEFUSE 3 in practice
Jadhav and Jovin, Stroke 2018
UPMC – 2667 AIS patients
![Page 87: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/87.jpg)
DAWN and DEFUSE 3 in practice
Jadhav and Jovin, Stroke 2018
UPMC – 2667 AIS patients
![Page 88: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/88.jpg)
DAWN and DEFUSE 3 in practice
Jadhav and Jovin, Stroke 2018
UPMC – 2667 AIS patients
![Page 89: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/89.jpg)
DAWN and DEFUSE 3 in practice
Jadhav and Jovin, Stroke 2018
UPMC – 2667 AIS patients
![Page 90: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/90.jpg)
DAWN and DEFUSE 3 in practice
Jadhav and Jovin, Stroke 2018
![Page 91: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/91.jpg)
DAWN and DEFUSE 3 in practice
• 10.5% of all AIS patients presenting to a CSC within 6 hours of symptoms onset qualify for endovascular therapy.
Jadhav and Jovin, Stroke 2018
![Page 92: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/92.jpg)
DAWN and DEFUSE 3 in practice
• 10.5% of all AIS patients presenting to a CSC within 6 hours of symptoms onset qualify for endovascular therapy.
• 1 in 3 patients with LVO and 5.7% of all AIS patients presenting in the 6-24-hour time window qualify for endovascular therapy based on DAWN criteria.
Jadhav and Jovin, Stroke 2018
![Page 93: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/93.jpg)
DAWN and DEFUSE 3 in practice
• 10.5% of all AIS patients presenting to a CSC within 6 hours of symptoms onset qualify for endovascular therapy.
• 1 in 3 patients with LVO and 5.7% of all AIS patients presenting in the 6-24-hour time window qualify for endovascular therapy based on DAWN criteria.
• One-third of DAWN eligible patients are DEFUSE 3 ineligible.
Jadhav and Jovin, Stroke 2018
![Page 94: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/94.jpg)
DAWN and DEFUSE 3 in practice
• 10.5% of all AIS patients presenting to a CSC within 6 hours of symptoms onset qualify for endovascular therapy.
• 1 in 3 patients with LVO and 5.7% of all AIS patients presenting in the 6-24-hour time window qualify for endovascular therapy based on DAWN criteria.
• One-third of DAWN eligible patients are DEFUSE 3 ineligible.
• Expanding treatment based on both DAWN and/ or DEFUSE-3 criteria would further broaden treatment eligibility to 9.2% of all patients presenting in the 6-24-hour time window.
Jadhav and Jovin, Stroke 2018
![Page 95: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/95.jpg)
DAWN and DEFUSE 3 in practice
• 10.5% of all AIS patients presenting to a CSC within 6 hours of symptoms onset qualify for endovascular therapy.
• 1 in 3 patients with LVO and 5.7% of all AIS patients presenting in the 6-24-hour time window qualify for endovascular therapy based on DAWN criteria.
• One-third of DAWN eligible patients are DEFUSE 3 ineligible.
• Expanding treatment based on both DAWN and/ or DEFUSE-3 criteria would further broaden treatment eligibility to 9.2% of all patients presenting in the 6-24-hour time window.
• A third of eligible patients are elderly (>80 years) and nearly half present as wake-up strokes.
Jadhav and Jovin, Stroke 2018
![Page 96: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/96.jpg)
Late presenter
![Page 97: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/97.jpg)
Acute Stroke Treatment 2018
• Extended time window is there!
![Page 98: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/98.jpg)
Acute Stroke Treatment 2018
• Extended time window is there!
• Time in Stroke is very important but Onset time is relative!
![Page 99: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/99.jpg)
AIS 2018
• Extended time window is there!
• Time in Stroke is very important but Onset time is relative!– Relative to:
• Collaterals
• Brain tissue/BBB
• Age, vascular risk factors
![Page 100: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/100.jpg)
AIS 2018
• Extended time window is there!• Time in Stroke is important but Onset time is relative!
– Relative to:• Collaterals• Brain tissue/BBB• Age, vascular risk factors
• Imaging selection with …?– DAWN and DEFUSE 3 … Perfusion or MRI DWI to identify
the core– AHA guidelines: Follow DAWN and DEFUSE 3 inclusion
criteria– Daily practice: ??
![Page 101: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/101.jpg)
Imaging selection
Nogueira
![Page 102: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/102.jpg)
Imaging selection
Nogueira
![Page 103: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/103.jpg)
Imaging selection
Nogueira
![Page 104: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/104.jpg)
Imaging selection
Jovin
![Page 105: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/105.jpg)
Stroke treatment: Exciting times!!
• EVT for acute stroke is one of the most effective treatments in Medicine.
![Page 106: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/106.jpg)
Stroke treatment: Exciting times!!
• EVT for acute stroke is one of the most effective treatments in Medicine.
• Wake up and late presenters (6 - 24h) should be considered for stroke treatment.
![Page 107: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/107.jpg)
Stroke treatment: Exciting times!!
• EVT for acute stroke is one of the most effective treatments in Medicine.
• Wake up and late presenters (6 - 24h) should be considered for stroke treatment.
• Onset time is relative but Revascularization time is very important.
• Move fast if patient qualify for EVT.
![Page 108: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/108.jpg)
Stroke treatment: Exciting times!!
• EVT for acute stroke is one of the most effective treatments in Medicine.
• Wake up and late presenters (6 - 24h) should be considered for stroke treatment.
• Onset time is relative but Revascularization time is very important.
• Move fast if patient qualify for EVT.
• Stroke networks and systems organization have to be consistent with new trials and guidelines.
![Page 109: Evidence and potential implications of the 6 24h EVT treatment … · Stroke treatment: Exciting times!! • EVT for acute stroke is one of the most effective treatments in Medicine](https://reader033.vdocument.in/reader033/viewer/2022042322/5f0cfa757e708231d43812d3/html5/thumbnails/109.jpg)
STROKE TEAM• Vascular Neurology
– Frank Silver
– Lee-anne Casabon
– Cheryl Jagobin
– Martin del Campo
– Alexandra Pikula
– Joanna Schaafsma
– Vascular fellows (2)
– Neurology resident in rotation
– Stroke nurses (5)
Interventional Neuroradiology
Ronit Agid
Richard Farb
Timo Krings
Vitor Mendes Pereira
Endovascular fellows (3)
Neurosurgery
Michael Tymianski
Ivan Radovanovic
Vascular neurosurgical fellows