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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
SGEM#70: The Secret of NINDS (Th…thesgem.com - 729 × 538 - Zoeken op afbeelding
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mrankin scale Luc
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!