Endovasculaire behandeling van acute stroke€¦ · - A1,A2 •IV treatment within 4.5 hours •IA...

Endovasculaire behandeling van acute stroke

Dr. Thierry Boulanger

Prof. dr. Sam Heye

Dr. Jos Smits

Dr. Luc Stockx

Dr. Jan Vanrusselt

Dr. Johan Vanrusselt

• 16u24 Oproep MUG

• 16u55 Aankomst ziekenhuis

• 17u03 Triage en assessment

urgentiearts

• 17u11 CT-schedel en CT-angio

• 17u12 Neurologisch consult,

• 17u43 Thrombolyse, arteriële en

DLP-Catheter, operatiekwartier

start-up

• 18u22 Start thrombectomie

• 18u50 Einde thrombectomie

• 19u00 Extubatie patiënt

Totaal:

87 min ‘in hospital’

31 min

8 min

8 min

32 min

39 min

Tijdslijn

18u50

TICI 3

TICI 3

• Duration of intervention: 28 min.

• Angiographic result: TICI 3

• Extubation and transfer to ICU

• In 2014, IV fibrinolysis was the only treatment that proved to

significantly improve the 3 months outcome (level of evidence 1A).

• Endovascular therapy is not superior to standard treatment with

intravenous t-PA

Endovascular treatment for Acute Ischemic Stroke, Ciccone et alN Engl J Med 2013; 368:904-913

2015: historical landmark in acute stroketreatment

To assess the effect of intra-arterial treatment on functionaloutcome after ischemic stroke caused by a proven intracranialarterial occlusion against a background of best medicalmanagement with or without IV t-PA

2015: historical landmark in acute stroketreatment

N Engl J Med 2015; 372:11-20 A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

Standard care +/- rt-PAStandard care +/- rt-PA

+IA treatment

N Engl J Med 2015; 372:11-20 A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

500 pts

MR CLEAN

• Acute ischemic stroke

• NIHSS ≥ 2

• Intracranial anterior circulation occlusion confirmed by CTA

- Distal ICA

- M1 M2

- A1,A2

• IV treatment within 4.5 hours

• IA treatment within 6 hours

MR CLEAN

N Engl J Med 2015; 372:11-20 A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

stent retrievers

Primary outcome

4. RCT X 6+++

MR CLEAN

P<0.05 CT

REVASCAT

P<0.05 ASPECTS

ESCAPE

P<0.001 Collaterals

SWIFT PRIME

P<0.001

RAPID 80%

EXTEND-IA

P<0.01 RAPID 100%

Endo-

vascular 33% 44% 53% 60% 71%

Control 19% 28% 29% 36% 40%

Go

od O

utc

om

e (

%)

Rankin

0-2

at 9

0 d

ays

Similar results in other RCT’s

Sufficient evidence from multiple randomized trials has resulted in significant

guideline modifications, with catheter-based endovascular therapy becoming

a class IA indication for all patients with acute stroke caused by a major

artery occlusion, provided that they present sufficiently quickly to the

healthcare system.

Karolinska Stroke Update level of evidence for treatment

recommendations, in collaboration with ESMINT and ESNR

AHA/ASA stroke guidelines

Acute stroke: recommendations

• Pertinent neurological deficit: NHISS ≥ 6

• Large vessel occlusion: M1 –M2, BA, ICA, carotid T, tandem

• ASPECT score: ≥ 4 if younger than 70

≥ 5 if older than 70

• COLLATERAL score

• No limitation of age but pre-mRS score 0-1

• Delay??

Patient selection in ZOL

0 no reperfusion

1 antegrade reperfusion but limited distal branch filling

2a antegrade reperfusion of less than half of the previously ischemic territory

2b antegrade reperfusion of more than half of the previously ischemic territory

3 complete antegrade reperfusion of previously ischemic territory

Angiographic result: TICI

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Clinical result at 3 months: mRS

05u30 (Turnhout):

• Right hemiplegia

• Afasia

• NHISS: 12

• CT: - Dens M1 sign

- ASPECT 10

• CTA: Left distal M1 occlusion

47 year old right-handed male

• 06u30:

- IV thrombolysis initiated

- transfer to ZOL

• 08u00:

- Arrival at ZOL

- NHISS: 12

- Thrombectomy initiated

47 year old right-handed male

8u30 (+3u)

9u10 (+3u40)

9u10 (+3u40)

• After 24 hours:

- Normal motoric function

- Slight dysphasia

• Retransferred

• After 1 week: complete recuperation

47 year old right-handed male

• Ménière’s disease

• 9 am (15-11-2014):

- vertigo, nausea, vomiting, headache

- D/ Ménière’s disease

- R/ Betaserc, Phenergan

- whole day in bed

• around 9 pm:

- worsening of symptoms

- hyperventilation, afasia, swallowing disorder, left hemiplegia

• 10 pm: emergency department

- diagnosed as Ménière’s disease

- evolution to “subcoma” while waiting in a box for further examination

• 11 pm:

- neurologist

- CT

• 11.30 pm: thrombectomy initiated

50 year old officer in Belgian army

• 17-11-2014: dismissed from intensive care

• 23-11-2014: dismissed from the hospital for further revalidation

• After 3 months: complete recuperation

50 year old officer in Belgian army

• Endovascular thrombectomy with or without IV thrombolysis has

become treatment of choice for acute stroke patients

• “Time is brain”

• Advanced brain imaging:

- ASPECT

- Collateral

• Angiographic result (TICI) vs. functional outcome at 3 months mRS

Conclusion

Bedankt voor uw aandacht!