The use of thrombectomy and the stroke network organization ESC Stroke Council 2017 Pr. Christophe Cognard University of Toulouse
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The use of thrombectomy and the
stroke network organization
ESC Stroke Council
2017
Pr. Christophe Cognard
University of Toulouse
Three levels of Evidence based
Medecine in acute stroke care
1. Hospitalization in a stroke unit: 100%
patients
2. IV t-PA: 10 to15%
3. Mechanical thrombectomy : 5 to 7 %
In 2015, seven randomized clinical
trials have shown the tremendous
efficacy of endovascular treatment
of acute stroke
mRs 2 at 3M
MT / IV in all studies
Odds ratio: 2.29
Today thrombectomy is
recommended
for LVO Stroke
of the anterior circulation
up to 6h after onset
European Consensus Statement on Thrombectomy(International Journal of Stroke)
ESOKSU
The things we know !
Thrombectomy must be performed in
LVO strokes
1) Anterior circulation
2) Even > 80 Y
3) In the first 6 h
4) After IV or not
No age limit
Even for M2 occlusion
But need case by case discussion
NIHSS / Proximal or distal M2 ?
Even in the posterior circulation (No
Evidence)
The things we don’t know!
The RCT we need
6 positive RCTs have answered one
question
And have risen a lot of
questions
We will not have from the 6 RCTs the
answers of the questions these RCTSs were
not designed to answer to
1) Should we do thrombectomy after
6 hours?
In which patients
Need for a RCT !
When to decide it is too late to do the
thrombectomy?
Slow/Rapid progressors!
There are futile very early recanalization < 4h
But useful late recanalization > 6h
Or only rely on imaging parameters ?
Two ongoing trials
Dawn and Defuse 3
Should we consider time from onset ?
2) Should IV be performed before
thrombectomy in LVO strokes ?
Need for a RCT !
In favor of IV:
• IV TPA may obtain a recanalization in 5 to 10% (specially if
short thrombus or residual flow)
• Distal thrombus migration (M1 to distal M2): early
neurologic improvement
• Softening thrombus for thrombectomy (less passes, less cost,
shorter procedure) ?
• Reperfusion of persisting distal emboli post thrombectomy !
Why not IV after thrombectomy in
LVO strokes ?
Against IV:
• IV t-PA Cost
• More symptomatic hemorrhages within/without the
infarct
• Increased delay to thrombectomy (drip and ship +++)
• Proximal thrombus migration
• Carotid stenting during EVT and need for immediate
antiplatelet therapy
Should IV t-PA be performed before
thrombectomy in LVO strokes ?
Need for a RCT !
3) Should the patient go in the nearest
stroke unit or directly to the thrombectomy
center?
Need for a RCT !
3) Should the patient go in the nearest
stroke unit or directly to the thrombectomy
center?
REVASCAT 2
Need for a RCT !
The future ?
All patients with NIHSS > 9 directly referred to
a thrombectomy center without IV TPA
No imaging but angioroom / Xpert-CT / Thrombectomy
Imaging only:
> 6h
NIHSS < 9
Stroke network in France
• 65 Million inhabitants
• 138 Stroke Units since 2007 (by law)
• 36 centers of INR (most in University
hospitals)
• INR centers connected to Stroke units by
telemedicine
Numbers of MT in France
• 2015:
1607
• 2016:
3671
And in 2020?
5 000 ?
10 000 ?
10 000 MT in France
277 MT per centre
And in 2020?
130 000 strokes in France/ Year
MT: 5 to 7 %
6 500 to 9 100 TM
116 000 coronary stenting in
2010!
In 2020,
endovascular treatment of brain
stroke
will represent around 7%
of endovascular treatment of cardiac
stroke
How many INR in France?
• Around 100 senior INR
• 36 fellows
• Number of INR per centre: 2 to 6
• Need for at least 4 INR per centre (144 in
France)
• Up to 6 in big centers
• So finally between 150 et 200 INR needed
in France
Thrombectomy in France
• MT only done in comprehensive INR centers
• Only by fully trained INR specialists
• 70% imaging done by MR
• 50 % MT done under GA
Thrombectomy in France:
Should we open new centers ?
• Why ?
• Some stroke units are too far away from INR
centers (>150 Km, > 1h)
• Or should we buy helicopters ?
Thrombectomy in France:
Should we open new centers ?
• Conditions for opening new centers:
– Must be > 150 Km or > 1h from the INR center
– Must do > 150 IV thrombolysis a year (80 MT)
But only very few do > 150 IV/Year
Requirement for opening a new
thrombectomy center (MT only)
• 24/7 Vascular neurologist (on call?)
• 24/7 Interventionist
• 24/7 CTA/CTP, MRA/MRP
• 24/7 Angioroom
• 24/7 Anesthesiologist
• 24/7 Neurosurgeon ?
Requirement for a thrombectomy
procedure
• 24/7 Interventionist: need for 4
• 24/7 Anesthesiologist
• 24/7 Technician
• 24/7 Nurse
What are the numbers in
Toulouse
• 2013: 50
• 2014: 80
• 2015: 180
• 2016: 240
• 2020: 300? 400?
3 Millions inhabitants
One thrombectomy center
12 Stroke Units
20 hospitals
1
2+
1
3
6
5
11
6
10
116
3
In 2015: 180 Thrombectomies done in
Toulouse
What are the numbers of patients addressed
for a MT to ToulouseUNV NO
PPR CHU 116Rangueil RANG 4Clinique des Cèdres CDC 3Saint-Gaudens SG 6CHIVA CHIVA 3Carcassone CARC 10Rodez RODEZ 1Auch AUCH 5Cahors CAHORS 3Tarbes TARB 11Albi UNV CHG ALBICHG 2ALBI UNV Cl. Bernard ALBICB 1Castres CAST 3Montauban MONT 6Clinique de l'Occitanie CDOCC 0L'Hôpital Joseph Ducuing HJD 0Clinique de l'Union CU 1Clinique Parc CP 1Hospital de Lavaur HL 1Clinique du Sidobre CS 1
TOT 178TOT - UNV 1 62
3 Millions
inhabitants
One thrombectomy
center
12 Stroke Units
20 hospitals
Maximum 10
patients /Year
Thrombectomy in France:
Should we open new centers ?
• Only very few
• Under the following Conditions :
– Must be > 150 Km or > 1h from the INR center
– Must do > 150 IV thrombolysis a year (80 MT)
• But we must improve patient transport
organization!
If a patient has a stroke 1H30 away from the
thrombectomy center
The time lost in transport is not all lost
During this time the INR/Anesthesiology
teams prepare everything for the MT
(30 to 60 min)
Things are done in parallel
So the need for a 1h 30 time to reach the INR
center should not be consider a 1h30 time
lost and patient lack of chance of good
outcomes but only 45min
60% of MT are done outside working hours
So the team has to come from home
(Interventionist, nurse, technician)
During working hours the angio-room is
usually occupied
Conclusion:
- Numbers of MT much smaller than for cardiology
- Need much less centers but with enough interventionists
( at least 4, better 6)
- With huge volumes (> 200/Y)
- Stroke dedicated angioroom
- Better transport organization
Thanks
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