acute ischemic stroke: time vs tissue · stroke treatment in 2010 yproblem: very few stroke...
TRANSCRIPT
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Acute Ischemic Stroke: Time vs Tissue
Greg Albers, MDCoyote Foundation Professor of Neurology and Neurological Sciences
Stanford University School of MedicineDirector, Stanford Stroke Center
Stanford University Medical Center
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Stroke Treatment in 2010
Problem: very few stroke patients receive treatment (5%)
Two treatments FDA approved:Intravenous tPA – treatment must begin <3-4.5 hrsMechanical devices; FDA approval but not clear who benefits and effective time window
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Advances in Stroke Imaging:Expanding the window for stroke therapy
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The Mismatch Concept
Core(dead)
Penumbra(salvageable)
• Infarct Core (game over):
Diffusion Weighted MRI (DWI)
• Penumbra or salvageable:
Perfusion Weighted MRI (PWI)
• Mismatch ratio:
Penumbra/Core
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The Mismatch Concept
Penumbra(salvageable)
Core(dead)
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DEFUSE Study
DWI / PWIEvaluation For Understanding Stroke Evolution
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6 hrsStroke score
16
PWI: 95 cc ↓ FlowDWI: 3 cc
4.5 hoursafter t–PA
Stroke score 5
6 cc Improved0 cc
Benefit of t-PA At 6 hrs in Mismatch Patients
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215 cc vessel occlusion105 cc
Beforet–PA
> 100 cc vessel open 77 cc
4 hoursafter t–PA
The Malignant Mismatch – t-PA Harmful
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Image Analysis
MR tech pushes DWI & PWI to
RAPID
Auto-send
Stroke MRI or CT 00:00Completion of scan
04:30RAPID image analysis complete
05:00Images on PACS
Automated Image Processing Required: RAPID Software
00:30image arrival
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DEFUSE 2 Protocol
MRIbaseline
Intra-arterial Therapy
MRIPost-procedure
(reperfusion)
MRIDay 5
(infarct volume)
Favorable clinical response:•NIHSS score of 0-1 at day 30 orimprovement of NIHSS score by ≥8 points between baseline and day 30
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88-Year-Old Female - IV t-PA Not Effective
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After mechanical clot removal
Complete neurologic recovery at 24 hrs
After Mechanical Clot Removal
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Use of Imaging to Monitor Stroke Therapies
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79 yo female, left side paralysis
CT Perfusion at 6.5 hours
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Blocked Artery Open at 8 Hours
Angiogram pre and post mechanical device
No blood flow to parts of brain Restored blood flow
Clot
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Blocked Artery Open at 8 Hours
Angiogram pre and post mechanical device
No blood flow to parts of brain Restored blood flow
Clot
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DWI at 16 hours
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DWI at 16 hours
Tmax at 16 hours
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DWI at 3 days
DWI at 16 hours
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88-Year-Old Female - IV t-PA Not Effective
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Mean MTT 8 Mean XE-CT CBF 15Mean Tmax 4s
61-Yr-Old, 7 hrs After Left Side Paralysis
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Recanalization at 6 hours after onset
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Baseline PWI lesion=153 cc
Early follow-up PWI lesion=45 cc
Final stroke size= 45 cc
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Tissue vs. Time
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62 yo male 2.5 hrs after symptom onset- CT PERFUSION
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Mean MTT 8 Mean XE-CT CBF 15 Mean Tmax 4s
82 yo female, iv tpa not effective, severe stroke symptoms
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Carotid artery open at 4 hours
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Mean MTT 8 Mean XE-CT CBF 15 Mean Tmax 4s
Follow-up MRI 4 hours later (8 after onset). Full recovery
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Baseline DWI lesion= 10 cc; NIH 22
Day 3: 5 cc
Baseline PWI lesion
Day 3: Flair lesion = 11 cc; NIH 0
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How to Increase theEffectiveness of Stroke Treatment:
• Use advanced imaging to triage and monitor therapy
• Don’t treat patients with severe irreversible damage
• Treat patients with salvageable tissue even if they arrive late
• Use intravenous tPA for small clots; mechanical devices for large clots
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DEFUSE 2 Coordinating Center
R. Bammer
M. MoseleyM. Mlynash
M. Marks
S. Kemp
J.M. Olivot
M. Straka
A. Purushotham
M. Lansberg