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Head, Neurointerventional Surgery &Interventional NeuroradiologyNEUROVASCULAR & STROKE CENTRE,Medanta-The Medicity
Dr Vipul Gupta
Interventions in stroke:Interventions in stroke:Evidence based managementEvidence based management
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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
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Endovascular neurointerventions !!!
Disease states different End- organ different- every area
important Reactive organ- reperfusion-
bleed Arteries different Access difficult- tortuosity
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Neurointerventions…
SAH- aneurysms, vasospasm Intracerebral hemorrhage- AVMs TIA- major vessel stenosis E/C & I/C Stroke- revascularization
Diagnosis- Imaging Interventional hardware Integrated approach
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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
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Penumbra and Treatment Options
0
10
20
30
min
CB
F (m
l/100
g/m
in)
300 9060 4120 5 6 24 48h
Infarct-threshold
Penumbra
Normal Vital tissue
InfarctSingle cellnecrosis
3
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IV tPA- indicationsASA/AHA guidelinesStroke - 2013
Less than 10% patients are eligible
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Issues with IV tPA
Time factor Large vessel disease Time to recanalize C.I. – anti-coagulants, recent surgery, wake-up strokes…. < 5 % qualify
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CT, CTA, CTP….
CT perfusion imaging
MTTCBF CBV
CBV – 2ml/gm- infarcted core; CBF, MTT - hyoperfusion area
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Concept of Penumbra
CBF/MTT CBVMatchedNo penumbra
CBF/MTTCBV
penumbra
CTA & CTP vs MR DWI & PWI
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Imaging approaches for case selection
NCCT (ASPECTS)- NIHSS NCCT & CTA, CTA-SI NCCT, CTA & CTP MRI-DWI, (MRA, PWI)
What information is needed?• Bleed• Infarct core – is critical 70-
100 ml• Major vessel occlusion• Tissue at risk- penumbra
Time, imaging interpretation, unstable patients
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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
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MR CLEAN(Netherlands)
ESCAPE(CANADIAN)
EXTEND IA(AUSTRALIAN)
SWIFT PRIME(USA)
REVASCAT(SPANISH)
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Comparison of protocol- Randomised (Intervention Vs Standard medical therapy)
• Documented MVO.- ICA, MCA (M1, M2)• Time based: 6 hrs (initiation of IA therapy)-
(8 hrs – REVASCAT; 12 hrs – ESCAPE)• Small Core - CT ASPECTS ≥ 6• CTP – EXTEND IA; SWIFT PRIME
• Predominantly stent retrievers. • 86.1 to 100% (100 % in EXTEND IA &
SWIFT PRIME)• (NIHSS scores were 17 (interquartile range,
13–21)
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TICI 2B/3 – 59% - 88% - (previous trials 25%, 41%)
Recanalization – TICI 2B/3
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Absolute Benefit (good outcome) : 13.5% to 31.4%(Statistically significant)
mRS (90 d)
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no significant difference
sICH
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Device complication
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Absolute mortality benefit : 8.6%(Statistically significant in ESCAPE)
Mortality
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Comparison of NNT:
EVT: NNT (benefit) - 3.1 to 4.2 (excluding MR CLEAN)
IV tPA ( 3 – 4.5 hours) – 13.8 (ECASS – 3)
Primary PCI (prevent re-infarction) – 33
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Clinical … Left hemiplegia, left UL and LL 0/5 5:14AM
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6:22AM
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8:07 AM
Patient made gradual recoveryLeft LL 4/5 and UL 3/5 - 30 day follow up mRS at 90 days- 0
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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
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Patient presented with in 2 hours
Futile IV tpa
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AHA/ ASA guideline 2015:Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
prestroke mRS score 0 to 1 acute ischemic stroke receiving intravenous r-tPA within 4.5
hours of onset causative occlusion of the internal carotid artery or proximal
MCA (M1) age ≥18 years NIHSS score of ≥6 ASPECTS of ≥ 6 treatment can be initiated (groin puncture) within 6 hours of
symptom onset
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AHA/ ASA guideline:Carefully selected patients with anterior circulation occlusion who have contraindications to intravenous r-tPA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable (Class IIa; Level of Evidence C).
Carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries (Class IIb; Level of Evidence C)
Waiting after IV tPA not required (Class III)
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Beyond 6 hours – Should you consider MT?
ESCAPE: up to 12-hours – positive trial
6 hours49 patientsrate ratio, 1.7; (95% CI, 0.7 to 4.0)
Not significant; however few numbers.
REVASCAT: upto 12 hours, positive trial
Data not provided.
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• 60 years old female.Acute onset left hemiparesis and left facial weakness; CT Brain , CTP and CTA done 6 1/2 hours after ictus.
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Our results Total No. of patients= 42 (M-19, F- 23) Time of arrival: 30 min- 840 min (mean 203.8 minutes) NIHSS at admission: 5-22 (Mean 14.33) MVO 39, IV tPA- 19
Good recanalization (TICI 2b or 3) in 57.1%mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)
Recanalization V/s Outcome
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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
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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)
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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
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Broad neck aneurysmBroad neck aneurysm
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Balloon assisted coiling
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Stent assisted coiling
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Dissecting blister aneurysm – poor gradeEVD
2-overlapping Enterprise stents 6-months follow-up
Blister/dissecting aneurysms
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Very small aneurysms
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Flow diverters (stents)- no coils
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Vasospasm- 15-25% morbidity and mortality
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Day 7
Continuous intra-arterial dilatation
Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.Anand S, Goel G, Gupta V.J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]
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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
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Our protocol Interventionist part of
neurosurgery team DSA & if possible embolization Neuro labwith 3D, CT NS ICU monitoring (TCD/CTP). Vasospasm- IAVD N- 540 (Jan 2014)
EmbolizationSurgery
91%
9%
Good outcomeFNDMortality
Mgt. outcome in good grade patients- 90 % mRS 0-2
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CAROTID ARTERY STENOSIS- 20-25% STROKES BY MAJOR VESSEL STENOSIS
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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
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STENTING FOR SEVERE CAROTID STENOSIS
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Patient with TIAs…..stenting done the next day
Should be done as soon as possible…maximum stroke risk in first few weeks
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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
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• Microemboli• Plaque morphology• Vasomotor reactivity• Silent infarcts • Progression
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Transient ischaemic attack
• Meta-analysis of 11 observational studies: Risk of stroke at 2, 30 and 90 days after TIA was 9.9,
13.4 and 17.3% respectively• Pooled analysis of 3206 pts with TIA and DWI
imaging, risk of stroke at 7 days was much lower in those without infarction compared to those with infarction: 0.4% vs 7.1%
Coull et al. BMJ 2004
Minor Cerebrovascular Syndrome
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ABCD3 ABCD3 – I score Multicenter pooled analysis:
UK + Ireland for Derivation model
Oxfordshire (UK) + California (US) for Validation model
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TIAs/minor stroke High risk of stroke in first few weeks Patients with DWI lesions and arterial stenosis have
higher risk Revascularization should be done soon
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CT Delayed …..
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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
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Clinical- Bleeding Seizures Neurological deficit Headaches Incidental
Cerebral Cerebral Arteriovenous Arteriovenous malformationsmalformations
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AVM- treatment options
Embolization Radiosurgery (Gamma Knife, LINAC, Cyberknife) Surgery
Embolization Glue (NBCA) vs Onyx embolization
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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
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Exciting time in neurosciences …
Interventional treatment methods for diseases like epilepsy, parkinsonism, headaches …..
Image guidance in neurosurgery Radiosurgery – Gamma Knife , Cyberknife Minimally invasive spine and brainsurgery Rapid evolution in approach Multidisciplinary , team approach
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For more information on:STROKE & NEUROVASCULAR INTERVENTIONS:
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Dr Vipul Gupta
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Thank You