alex abou-chebl, md, fsvin medical director, …...powers wj, et al. 2015 aha/asa focused update of...
TRANSCRIPT
What Cardiologists Need to Know Before Becoming Stroke
Interventionists II: How to Use Modern Neuro-
Interventional Tools and Techniques to Optimize Stroke Outcomes
Alex Abou-Chebl, MD, FSVIN
Medical Director, Stroke
Baptist Health Louisville
Disclosure Statement of Financial Interest
• Consulting Fees/Honoraria • The Medicines Co.
• Silk Road Medical
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Essential Components of
Endovascular Therapy
• Patient Selection
• Appropriate Team Members
• Rapid Triage to Interventional Lab
• Identification of Site of Occlusion
• Stable Access
• Pharmacological Rx Selection
• Equipment Selection
• Respect the Artery
• Know When to Stop
• Post-Op Care
Patient Selection
• Intracerebral Hemorrhage is the Wolf
Nipping at Your Heels
Predictors of ICH
• Severity of deficit- NIHSS≥20
• Duration Of Ischemia
• Size of Infarction- necrotic core, ASPECTS<5
• Size of penumbra
• Blood Pressure
• Blood Glucose
• Patient Age
• Pharmacological Milieu
• Collaterals
• Dementia
• Device
• Choice of Anesthesia
Avoid General Anesthesia in Acute
Ischemic Stroke EVT
• 12 centers N=980: 44% GA
90d poor outcome OR 2.33 (1.63-3.44), p<0.0001
Mortality OR 1.68 (1.23-2.30), p<0.001
• NASA Registry
90d poor outcome aOR 2.4 (1.2-5.1), p=0.01
Mortality aOR 3.3(1.6-7.1), p=0.001
• IMS III
90d good outcome aOR 0.68 (0.52-0.9), p=0.0056
Mortality aOR 2.84 (1.65-4.91) p=0.0002
Abou-Chebl A et al. Conscious sedation versus general anesthesia during endovascular therapy for acute
anterior circulation stroke: Preliminary results from a retrospective multi-center study. Stroke
2010;41(6):1175-9
Abou-Chebl A, et al. North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry: Choice of
Anesthesia and Outcomes. Stroke 2014;45(5):1396-1401
Abou-Chebl A, et al. Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of
IMS III. Stroke 2015;46(8):2142-8
Identifying Location of Occlusion
• Excellent Angiographic Technique
Multiple Angles- Steep AP and True Lateral
Large field of view imaging entire skull and scalp
Delayed Filming
Cortical Blush
Vessel Cutoff
Early Venous Shunting
Retrograde Filling
Clinical Correlation
Illustrative Case
Man With Wernicke’s Aphasia
Stable Access
• Stable Access vs. Time
8F Balloon Guide in proximal ICA or
Subclavian (? VA)
Rarely sheath in common carotid for
extreme proximal tortuosity
Distal access catheters in severe
proximal/distal tortuosity
Pharmacological Rx Selection
• Heparin
Major risk factor for ICH• PROACT II Trial- 2000U bolus then 500U/hr X4hrs
• Thrombolytics- Limited need- ICH proportional to dose
tPA- 5-20mg
Retevase 2-5U
Urokinase 4-600,000U ?
• GPIIb/IIIa
Post-stenting
IA or IV
¼-1/2 bolus, never an indication for continuous infusion
• NTG
Furlan A, et al. PROACT II. JAMA 1999;282(21):2003-2011
Abou-Chebl A, et al. Multi-modal Therapy for the Treatment of Severe Ischemic Stroke
Combining GPIIb/IIIa Antagonists and Angioplasty after Failure of Thrombolysis. Stroke
2005;36(10):2286-2288
Equipment Selection
• 6-8F Sheath
• 6F Neuro-guide catheter
• 8F Balloon-guide catheter (7F and 9F available)
Merci™, Cello™
Essential- greatly increases recanalization efficacy
• Hydrophilic 014” soft neurowire
Rarely medium weight to get access
Never stiff wire or CTO wires
Transcend™, Synchro™
• Neuro Microcatheter
Marksman™, Trevo™, Rapid Transit™, etc.
Nguyen T, et al. Balloon guide catheter improves revascularization and clinical
outcomes with Solitaire device: Analysis of NASA Registry. Stroke 2014;45(1):141-145.
Equipment Selection
• Stent Retriever Device- 1st Line per AHA
Guidelines
Solitaire FR™
• 3x20, 3x30, 4x15, 4x20, 4x30, 6x20, 6x30
Trevo XP Provue™
• 3x20, 4x20, 6x25
• Penumbra Aspiration System™
• Multiple variant techniques
Push and fluff
ADAPT
Solimbra
Powers WJ, et al. 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early
Management of Patients With Acute Ischemic Stroke Regarding Endovascular
Treatment Stroke. 2015;46
Respect the Artery
• Intracranial Vessel Histology
No external elastic lamina
Minimal adventitia
Thin tunica media/muscularis• ICA above ophthalmic
• VA at foramen magnum
• Subarachnoid course
Near Microscopic perforators• MCA Trunk
• BA Trunk
• BA Apex-PCA
Respect the Artery
• No touch technique
• Never over-size
• Softest equipment possible
• Know your variants
Fetal PCA ~20%
Circle of Willis complete in 25%
Anterior temporal
Early MCA bifurcation/trifurcation
BA cerebellar branches
Basilar tip configuration
Trigeminal Artery
• Guide position
• “Better is the enemy of good”
When Do You Stop?
Illustrative Case
• 78yo WM with HTN, Hyperlipidemia, Cigs
• Developed mild aphasia and right
hemiparesis
• Hospitalized
• MRI shows multiple small infarcts
• Tx w Aspirin pending W/U
• 3rd Hosp Day develops complete LICA
syndrome
LCCA Angiogram
Post-Stenting Angiogram
Reopro 20mg Given IA
When To Stop
• Over 1 hour- ?
Over 2 hours- definitely
• >2 devices or approaches
• Clinical deterioration
• Poor Collaterals
• Weigh Risks
Wire perforation
Reperfusion Injury
Distal embolization
Age
Initial infarct size
BP
Glucose
Complications of Acute Stroke
Intervention
• Intraprocedural
Spasm
Dissection
Perforation
ICH
Failure
• Post-procedural
Reperfusion ICH
Cerebral Edema
Perforation & Intraoperative ICH
Management
• You only have seconds
Reverse all anticoagulants/antithrombotics
Lower SBP <100mmHg
Tamponade
• Gentle balloon- don’t create bigger tear
• Occlude vessel- microcatheter, coils, glue
Leave the vessel occluded, you’ve done
enough
Call the Neurosurgeons
• But it will not do the patient any good, with rare
exception
Post-Op Care
• No Heparin or antithrombotics X24hrs minimum
Unless emergent stent then ASA and Plavix but risk of
ICH increased
• BP Control
IV tPA <185/110
IA tPA <185/110
My Recommendations
• Recanalyzed vessel SBP<120
• Partially recanalyzed SBP<150-160
• Neuro-ICU: improved outcomes
• Repeat CT at 24hrs or with any deterioration or
new/progressive headache
Stroke Neurologist
• Team Leader
• Protocols
• Patient Selection Criteria
• Acute Evaluation
• Treatment decisions
• Post-treatment management
• Etiology determination
• Management of Medical Complications
Summary
• Select patients appropriately
Small necrotic core
Large ischemic penumbra
• Do not overdose pharmacological agents
• Know cerebral anatomy
Know where you are placing your device
• Use the softest, least aggressive device for the
job
• Do not put patients to sleep
• Know when to stop
Goal is neurological improvement not an open artery