Centre Hospitalier Universitarie Vaudois Centre cerebrovasculaire Update phase aguë de l'AVC Chef de Clinique, Centre Cérébrovasculaire Service de Neurologie, Départment des Neurosciences Cliniques Dr. Davide Strambo 26 Septembre 2019
Centre Hospitalier Universitarie Vaudois Centre cerebrovasculaire
Updatephaseaguëdel'AVC
Chef de Clinique, Centre Cérébrovasculaire Service de Neurologie,
Départment des Neurosciences Cliniques
Dr. Davide Strambo
26Septembre2019
Outline• AVCischémique
– Nouveautés• Thrombolysepourdébutinconnu/auréveil• Thrombectomietardive• Thrombolysetardive
– Perspectives• Thrombectomiedirectevs.Bridging• Tenecteplase
• Hemorragiecérébrale• Tensionarterielle• Reversiondelacrase• Transfusiondeplaquettes
REVASCULARISATIONAIGUE
REVASCULARISATIONAIGUE
Oùonétait…..
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Trial
Fenêtrethérapeutique
NINDS
ECASSI
ECASSII
ATLANTIS
ECASSIII
IST-3
Guidelines
ThrombolyseIV-rtPAOùonétait…
4.5h3h 6h
EmbersonJ,Lancet2014;ESOguidelines,CerebrovascDis2008;PowersW,Stroke2018
5h
ThrombectomieOùonétait…
Trial Fenêtrethérapeutique
MR-CLEAN
ESCAPE
EXTEND-IA
SWIFT-PRIME
REVASCAT
THRACE
Guidelines
6h 8h5h 12h
SaverJ,JAMA2016;TurcG,ESJ2018;PowersJ,Stroke2018
Enresumé
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Oùonétait…
Strokeonsetorlastseenwell
CourtesyofProf.PatrikMichel
Lesbarrieresàsurmonter
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
REVASCULARISATIONAIGUE
Lesnouveautés…
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Lesbarrieresàsurmonter
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
Debutinconnu/aureveil
ThomallaG,LancetNeurol2011
Debutinconnu/aureveil
ThomallaG,LancetNeurol2011
Debutinconnu/aureveil
OR1.61(1.09to2.36)2
1FromEmbersonJ,Lancet20142ThomallaG.NEJM2018
Favorableclinicalresponse(OR)
Harm0.5 0.6 1.0 1.5 2
<3h
3–4.5h
WAKE-UPtrial
BenefitNoeffect
OR1.26(1.05to1.51)1
OR1.75(1.35to2.27)1
ThrombolyseIV
Debutinconnu/aureveil
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Strokeonsetorlastseenwell
Ifonsetunknownoratwake-upàIVTrtPAifDWI+/FLAIR-
Lesbarrieresàsuperer
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
Leconceptdumismatchcore/penombre• Ischemieirreversibile
(core)– MRI-DWI– CTnatif– CTdeperfusion
• Ischemiereversible(penombre)– MRIdeperfusion– CTdeperfusion– Deficitclinique
Leconceptdumismatchcore/penombre• Ischemieirreversibile
(core)– MRI-DWI– CTnatif– CTdeperfusion
• Ischemiereversible(penombre)– MRIdeperfusion– CTdeperfusion– Deficitclinique
L’applicationduconceptdumismatch
OR1.86(1.15to2.99)
MaH,NEJM2019;CampbellB,Lancet2019;
NogueiraR,NEJM2017;AlbersG,NEJM2018;SnellingB,JNeurosciRuralPract2019
Favorableclinicalresponse(OR)
Harm0.3 1.0 3
<3h
4.5-9hMissmatch+
BenefitNoeffect
OR1.75(1.35to2.27)ThrombolyseIV
0.5 2 50.2
L’applicationduconceptdumismatch
OR1.86(1.15to2.99)
MaH,NEJM2019;CampbellB,Lancet2019;
NogueiraR,NEJM2017;AlbersG,NEJM2018;SnellingB,JNeurosciRuralPract2019
Favorableclinicalresponse(OR)
Harm0.3 1.0 3
<3h
4.5-9hMissmatch+
BenefitNoeffect
OR1.75(1.35to2.27)ThrombolyseIV
Thrombectomie<6-8h
6-24hMissmatch+
0.5 2 50.2
OR4.02(2.02to8.02)OR6.25(3.12to12.5)
OR2.49(1.76to3.53)
DAWN
DEFUSE-3
Enresumé
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Lesnouveautées…
Strokeonsetorlastseenwell
Enresumé
EmbersonJ,Lancet2014;SaverJ,JAMA2016;NogueiraR,NEJM2017;AlbersG,NEJM2018;MaH,NEJM2019;CampbellB,Lancet2019
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Lesnouveautées…
Strokeonsetorlastseenwell
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
8 - 9 - 24 hours
Enresumé
EmbersonJ,Lancet2014;SaverJ,JAMA2016;NogueiraR,NEJM2017;AlbersG,NEJM2018;MaH,NEJM2019;CampbellB,Lancet2019
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Lesnouveautées…
Strokeonsetorlastseenwell
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
8 - 9 - 24 hours
REVASCULARISATIONAIGUE
Perspectivespourl’avenir…
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Bridging?
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Perspectivespourl’avenir
Strokeonsetorlastseenwell
SWIFT-DIRECTMRCLEAN-NOIV
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
IV Thrombolysis rtPA
Tenecteplase?
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
EVT if LVO and mismatch criteria met
Perspectivespourl’avenir
Strokeonsetorlastseenwell
TNK?
CouttsS,IntJStroke2018BurgosA&SaverJ,Stroke2019;
Hill&Michel,Stroke2019
Late IV thrombolysis rtPA if mismatch criteria met
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
TNK?
TNK?
TRAITEMENTAIGUDEL’HEMORRAGIECÉRÉBRALELesnouveautés…
Traitementaigudel’hemorragiecérébrale
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
Hemorragiecérébrale
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
OR1.11(1.05to1.17)
Favorableclinicalresponse(OR)
Harm0.5 0.6 1.0 1.5 2
10mmHgreductiondelaTA
systolique
BenefitNoeffect
INTERACT-2Trial:AndersonC,LancetNeurol2008ATACH-2Trial:QureshiA,NEJM2016
MoullaaliT,LancetNeurol2019HemphillJC,Stroke2015;SteinerT,IntJStroke2014
Dansles6heuresaprèsledebutdel’HICSilaTAsystoliqueest>150mmHgàTargetTAS<140mmHgdans1heure
Pasdeconcernesurlasecurité
Hemorragiecérébrale(sousanticoagulants)
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
Dabigatranàidarucizumab(Praxbind®)• DisponibleenSuissedepuis2016• DisponibleauCHUV• Cout~3’000.-Apixaban,rivaroxaban,edoxabanàandexanetalfa(Ondexxya®)• AutoriséparEMA• BientotdisponibleenSuisse• $$$$$$$$$$$$$$$$$• Indicationsàdéfinir
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
RE-VERSEAD:PollackC,NEJM2017ANNEXA-4:ConnollyS,NEJM2019
Hemorragiecérébrale(sousantiplaquettaires)
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
PATCHtrial:BaharogluMI,Lancet2016
OR0.48(0.28to0.85)
Favorableclinicalresponse(OR)
Harm0.2 0.5 1.0 2 5
Transfusiondeplaquettes
BenefitNoeffect
Pasdebenefice,probablementplusd’effetssecondairesHemorragiesseveres(GCS<8)excluesdel’étude
TakehomemessagesAVCischemique• L’imagerieavancépermetdeselectionnerlespatientspour
revascularizationjusqu’à24heuresHemorragiecèrèbrale• Baisserlatensionarteriellesystolique<140mmHg• Reverserlacrase• Pasdetransfusiondeplaquettespourhemorragieslegeres/moderéssous
antiplaquettaires
Centre Hospitalier Universitarie Vaudois Centre cerebrovasculaire
Question?
Mercipourl’attention