alex abou-chebl, md, fsvin medical director, …...powers wj, et al. 2015 aha/asa focused update of...

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