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Endovascular Treatment of
Acute Ischemic Stroke
Mahmoud Rayes, MD
Disclosures
• None
Definition of
Ischemic Stroke
Acute onset
Focal neurological deficit
Vascular occlusion
Clinical diagnosis
http://www.strokecenter.org/patients/about-stroke/ischemic-stroke/
Someone in the United States has a stroke every 40 seconds on average
One American dies from stroke every 4 minutes
The stroke belt (Southeastern US) have a substantially higher stroke rate than the national average
North Carolina, South Carolina and Georgia comprise the Buckle of the Stroke Belt (Stroke mortality rates up to 3 times the national average)
According to the WHO, 15 million people suffer stroke worldwide each year
Annual deaths per 100,000
Epidemiology
A blood vessel supplying the
brain is occluded
Loss of oxygen and
nutrients causes cell hypoxia
and depletion of cellular
adenosine triphosphate (ATP)
Without ATP, there is no
longer the energy to maintain
membrane integrity
Influx of sodium and calcium
ions and passive inflow of
water into the cell lead to
cytotoxic edema
http://www.strokecenter.org/patients/about-stroke/ischemic-stroke/
Risk Factors
• Hypertension
• Diabetes mellitus
• Cardiac disease (A fib)
• Hyperlipidemia
• Age
• TIAs/stroke
• Etc
Symptoms
• Depends on location of stroke
– Weakness
– Numbness
– Vision loss
– Aphasia
– Ataxia
http://www.strokeassociation.org/STROKEORG/WarningSign
There are two types of blood
clots:
A clot that forms inside the
vessel called a cerebral thrombus
A clot that breaks loose and
moves through the blood to the
brain called a cerebral embolism
Embolic stroke
Embolic Stroke
Embolic Stroke
Time is brain
Stroke. 2006; 37: 263-266
Radiology assistant.nl
• Affected regions with cerebral blood flow of
lower than 10 mL/100 g of tissue/min are
referred to as the core
• Zones of decreased or marginal perfusion
(cerebral blood flow < 25 mL/100 g of
tissue/min are reffetred to as the penumbra
Latchaw RE, et al. Guidelines and recommendations for perfusion imaging in cerebral ischemia: A scientific statement for healthcare professionals by the writing group on perfusion imaging, from the Council on Cardiovascular Radiology of the American Heart Association. Stroke. 2003 Apr. 34(4):1084-104
• The chance of a favorable outcome decreases by
approximately 20% for every 30 minute delay in
recanalization
Meta-analysis Shows a Strong Correlation
Between Revascularization and Good Patient
Outcomes
*Differences in sICH were not statistically significant between the revascularized and non-revascularized groups
Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007 Mar;38(3):967-73.
58.1%
14.4% 13.7%
24.8%
41.6%
12.5%
0%
10%
20%
30%
40%
50%
60%
70%
Good Outcome(mRS 0-2)
90-Day Mortality SICH
% o
f P
ati
en
ts
Revascularized Non-revascularized
*
Options for Patients Experiencing an
Ischemic Stroke
Endovascular Clot Removal
IV tPA Gold-standard in ischemic
stroke care.
Medical Management
Monitor vitals and provide secondary stroke prevention.
Bridging Therapy
• 1950s
• Recognition that carotid bifurcation disease could
cause cerebral infarction
• Transient ischemic attack (TIA) are warning
symptoms
• First carotid endarterectomy performed
• Prosthetic heart valves introduced to patients with
rheumatic heart disease to lessen the risk for
embolic stroke
Neurology Today: April 2002 - Volume 2 - Issue 4 - p 13
• 1960s
• Severe hypertension identified as a treatable risk factor for stroke
• Doppler ultrasonography developed
• 1970s
• Demonstration that aspirin is effective in preventing stroke
• Development of computerized tomography (CT)
• Recognition of the management of risk factors for stroke associated with major decline in stroke mortality
Neurology Today: April 2002 - Volume 2 - Issue 4 - p 13
• 1980s
• Development of MRI
• Interventional neuroradiology
• Other antiplatelet agents are demonstrated to be effective in lessening the risk of stroke
• Cigarette smoking is established conclusively as a major risk factor for stroke
• 1990s
• Carotid endarterectomy is proven effective in preventing stroke among patients with severe stenosis
• Oral anticoagulants and aspirin are shown to be very effective in lessening the risk of stroke among persons with atrial fibrillation
Neurology Today: April 2002 - Volume 2 - Issue 4 - p 13
• Approximately 8% of ischemic stroke patients
are eligible for IV tPA
• In large part due to arriving to the ED beyond
the 3 hour time window
• There are a lot of contraindication
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587. Kleindorfer DO, Broderick JP, et al. Emergency department arrival times after acute ischemic stroke during the 1990s. Neurocrit Care. 2007;7(1):31-5.
31%
8%
24%
35%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
All ICA MCA Stem MCA Divsn MCA Branch
% Recanalized
Del Zoppo et al., Ann Neurol 1993
• IV-rtPA recanalization rates for large vessel occlusions in comparison to smaller vessel occlusions is lower.
Thrombolysis Stroke Study
Overview
Recanalization Good Outcomes
(mRS ≤ 2) Mortality Symptomatic
ICH
NINDS N/A 43.0% 21.0% 7.0%
ECASS III N/A 52.4% 7.7% 2.4%
PROACT I N/A 58.0% 27.0% 15.0%
PROACT II 66.0% 40.0% 25.0% 10.0%
IMS I 56.0% 43.0% 16.0% 6.0%
IMS II 66.0% 46.0% 16.0% 10.0%
• Thrombolysis Stroke trials have demonstrated improved good outcomes rates varying from 39%-58% vs. placebo with acceptable safety risks of ICH (2.4%-15%). • Thrombolysis is and should be the standard of care for AIS patients.
*AJNR 30:859-75: May 2009
Endovascular treatment
• Multiple negative trials
– IMS III
– SYNTHESIS
– MR RESCUE
IMS III
• Trial stopped early because of futility after 656
participants had undergone randomization
– 434 ED and 222 IV tPA
• No difference in:
– mRS at 90-days (40.8% ET; 38.7% IV tPA)
– 90-day mortality (19.1% ET; 21.6% IV tPA)
– SICH within 30 hours (6.2% ET; 5.9% IV tPA)
Joseph P. Broderick, Yuko Y. Palesch, Andrew M. Demchuk et al.: Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. N Engl J Med 2013. DOI
Common Issues
• Good clinical outcome following angiographic
reperfusion with IA therapy is strongly time-
dependent
• The time to endovascular treatment in the IMS
III trial was 32 minutes longer than in the IMS I
trial
• Limited use of newer technology such as stent
retrievers
Dawn of New ERA
Endovascular & Medical Management
vs. Medical Management Alone
Trial Time from symptom onset
Device Imaging Primary outcome Comments
ESCAPE < 12 hrs Any IAT (86% stent retriever)
CT/CTA - Confirmed LVO - ASPECT > 5 - Small core infarct
on CTA or CTP
NIHSS or mRS 0-2 at 90 days
Positive for IAT + IV tPA
MR CLEAN < 6 hrs Any IAT (97% stent retriever)
CTA/MRA/DSA/or TCD confirmed LVO
mRS at 90 days Positive for IAT + IV tPA
EXTEND-IA < 6 hrs Stent Retriever
(Solitaire FR)
CTA/CTP or MRA/MRP -Confirmed LVO -Mismatch on
perfusion -Core infarct < 70 cc
Reperfusion at 24 hrs NIHSS 0-1 or
reduction >/= 8 points at 3 days
Positive for IAT + IV tPA
SWIFT PRIME
< 6 hrs Stent Retrievers (Solitaire FR)
CT/CTA or MRI/MRA -Confirmed LVO -Core infarct < 1/3 MCA or < 100 cc -ASPECTS > 5
mRS at 90 days Positive for IAT + IV tPA
LVO = Large Vessel Occlusion Information taken from www.clinicaltrials.gov
MR CLEAN
Common adjusted odds ratio: 1.67 (95% CI: 1.21 to 2.30)
O.A. Berkhemer et. al. A Randomized Trial for Intraarterial Treatment for Acute Ischemic Stroke. N Eng J Med December 2014.
ESCAPE
Common adjusted odds ratio: 3.1 (95% CI: 2.0 to 4.7)
M Goyal et. al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. NEJM published on February 11, 2015
SWIFT PRIME
Jeffrey L. Saver et. al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. NEJM Published April 17, 2015..
EXTEND IA
B.C.V. Campbell et. al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. NEJM published on February 11, 2015
Numbers needed to treat
• MR CLEAN: 7 in favor of intervention
• EXTEND-IA: 3 in favor of intervention
• ESCAPE: 4 in favor of intervention
• SWIFT-PRIME: 4 in favor of intervention
• CEA for symptomatic carotid stenosis (>70%): 6
• Aspirin for secondary stroke prevention: 200
• Coumadin in Atrial Fibrillation: 3
• Hemicraniectomy for malignant stroke: 2
Solitaire
Trevo
Case #1
• 74 Y/O Female brought in by EMS
• Last seen normal 16:00
• Groin puncture17:40
• NIHSS 22
• t-PA administered
CT head
CTA
Angiogram – MCA
Occlusion
TICI 3 Flow
MRI Post Procedure
6 Week Follow Up
• NIHSS 0
• mRs 0
Case #2
• 71 Y/O Male last seen normal at 7 AM
• NIHSS 18
• tPa administered
• Procedure started at 9:05 AM
CT and CTA
Angiogram – Basilar
Occlusion
MER
• Pre procedure NIHSS 18
• Procedure started at 9:05 AM
• Procedure completion 9:24 AM
• Door to recanalization 67 minutess
• Post procedure NIHSS 1
QUESTIONS?
