neurointervention in hemorrhagic and ischaemic stroke

Vipul Gupta

Head, Neurointerventional Surgery NEUROVASCULAR & STROKE CENTRE

Neurointervention in hemorrhagic and ischaemicstroke: recent advances

Neurovascular diseases…Stroke…. Third most common cause of death

Most common reason for disability

Appx. 1 in 4 people die within 1 year

30%–50% do not regain functional independence

Annual incidence rate of stroke in India currently is 145 per 100,000 population

10 - 15% occur in < 40 years

WHO estimates suggest that by 2050, 80% stroke

cases in the world would occur in low and middle

income countries mainly India and China

Neurointerventions…

SAH- aneurysms, vasospasm

Intracerebral hemorrhage- AVMs

TIA- major vessel stenosis E/C & I/C

Stroke- revascularization

Diagnosis- Imaging

Interventional hardware

Integrated approach

Neurointervention Cath

Lab- Biplane flat panel, 3D

imaging, Road map, Dyna

CT

NEUROINTERVENTION EVOLUTION…….

Inbuilt CT..

Devices - coils, catheters, balloons, stents

Imaging-

understanding

ANEURYSMS- basic facts

• Subarachnoid hemorrhage (SAH).• One in every 20 strokes , at the

prime of ones life (commonly between 40-50yrs).

• Up to 40-50% patients do not survive even for a month mostly because of the rerupture of the aneurysm

• With proper treatment up to 90% of patient who reach hospital before any major damage has happened will lead an independent and productive life

Initial CT Scan

Rebleeding after 1 day

Clipping vs coiling…

Initially Surgically inappropriate

Tremendous changes in last 15-yrs

Cerebral Aneurysms-

• Image-guidance (3-D , Dyna-CT)

• Coil, catheter, balloons, stents

• Drugs- aspirin, clopidogrel, abciximab

• Appx. 90% by endovascular

• Intra-arterial vasospasm mgt.

• HELP and Cerecyte studies – mRS 0-2 in 87% (80% in ISAT)

Broad neck aneurysm

Balloon assisted coiling

? Near the neck rupture

Double balloon technique

Stent assisted coiling

Dissecting

blister

aneurysm –

poor grade

EVD

2-overlapping Enterprise stents 6-months

follow-up

Blister/

dissecting

aneurysms

Very small aneurysms

Flow diverters (stents)-

6-months F/U

Day 6 Confused, slightly weak on right side

CT perfusion for vasospasm mgt

Day 7

Continuous intra-arterial dilatation

Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.

Anand S, Goel G, Gupta V.

J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]

ISAT Randomized, prospective,

international trial

Clipping vs coiling

9559 patients screened, 2143 randomized

at 1 year, the difference in the risk of dependency or death between the two groups was 6.9% and the relative risk reduction was 22.6% (in the coiling group) ISAT follow-up, Lancet 2009- death at 5 years lower

The Barrow Ruptured Aneurysm Trial

Compared clipping vs coiling in SAH patients. Poor outcome - 33.7% in clipping vs 23.2% in coiling

Guidelines for the Management of Aneurysmal SAH: Special Writing Group of the Stroke Council, ASA/AHA Stroke 2009

Amenable to both endovascular coiling and neurosurgical

clipping, endovascular coiling can be beneficial (Class I, Level

of Evidence B).

Metanalysis

• Stroke 2013

• AJNR 2013

• Ruptured aneurysms- better outcomes

after endovascular management

Our protocol

Interventionist part of neurosurgery team

DSA & if possible embolization

Neuro labwith 3D, CT NS ICU monitoring

(TCD/CTP). Vasospasm- IAVD

N- 540 (Jan 2014)

Embolization

Surgery

91%

9%

Good outcome

FND

Mortality

Mgt. outcome in good grade patients- 90 % mRS 0-2(Submitted for publication)

CAROTID ARTERY STENOSIS-

20-25% strokes by major vessel stenosis

Symptomatic Stenosis

• Non-invasive >70%

• Catheter angiography >50%

• Peri-procedural risk <6%

Asymptomatic Stenosis

• >70% Stenosis

• Periprocedural complication risk is low

• Life expectancy >5 yr

• >80% stenosis- tend to be treated

Revascularization indications-

ASA/AHA guidelines 2011

STENTING FOR SEVERE CAROTID STENOSIS

Patient with recurrent TIAs…..stenting done the

next day

Should be done as soon as

possible…maximum stroke risk in first few

weeks

CAS vs CEA- CREST – NEJM 2011

•2502 patients- Outcome largely same

•More MI in surgery ; more minor strokes in CAS

•Stenting better in 70yrs and less age group

•Nerve palsies not included in end-points

•Less than 1% major stroke

ASA/AHA guidelines 2011-Endarterectomy and stenting are alternatives

(Class I evidence)

Early intervention is advisable

Pivotal randomized trials

Issues-

Use of embolic protection devices

Lead in/training phase/experience required

MI as point of evaluation

Cranial nerve injuries and local complications

Long-term mortality after peri-procedural events: No association with minor stroke, but strong association of MI

Neurological Residual Deficit Rates by NIHSS Associated with Minor Strokes, Equal at 6 months

No observed CAS-relatedcranial nerve injury (CNI)

Treatment protocol at Medanta

Active endovascular (INR)- 50/year- mostly symptomatic; Cardiology – 20/year

Active endarterectomy (CTVS, VS)- 80-90/many incidental combined with CABG

We offer both options - thrombus, excessive tortuosity/kinking, diffuse disease- send to CEA

“It is not the procedure but expertise matters”

Intracranial atherosclerosis Intracranial arterial stenosis is responsible for 6% to

10% of ischemic strokes in whites and 22% to 26% of ischemic strokes in Asians

SAMPRIS Trial- stenting not to be

done as routine in acute stroke

•Recurrent symptom

•Subocclusive stenosis

ISCHAEMIC stroke- brain attack

Intravenous thrombolysis

* Time limitation-<3-4.5 hrs• Not effective in large

vessel occlusion

• Many contraindications

Role of I/A therapy Chemical thrombolysis Mechanical

recanalization

ISCHAEMIC stroke – saving the penumbra

Issues with IV tPA

Time factor (<4.5 hrs)

C.I. – anti-coagulants, recent surgery, wake-up strokes….

<10% eligible

Large vessel disease

Time to recanalize

•Distal MCA – 44%

•Proximal MCA - 30%

•Terminal ICA - 6%

•Tandem cervical ICA/MCA -27%

•Basilar artery- 30%

Prerecombinant tissue plasminogen activator, National Institutes of

Health Stroke Scale score, systolic blood pressure, glucose, and

Thrombolysis in Brain Ischemia flow grade at the occlusion site were

the negative independent predictors for complete recanalization in the

final model.

• 53 studies, 2066 patients

• Sp.- 24%, IV tPA- 46%, IA- 64%, Mechanical- 84%

• Good outcome more in recanalized patients (OR- 4.4)

• Less mortality in recanalized patients

CT, CTA, CTP…. – LVO, penumbra

Perfusion imaging

MTTCBF CBV

CBV – 2ml/gm- infarcted core;

CBF, MTT - hyoperfusion area

Concept of Penumbra

CBF/MTT CBVMatched

No penumbra

CBF/MTTCBV

penumbra

CTA & CTP vs MR DWI & PWI

PENUMBRA, 2007MERCI, 2004

STENTREIVERS- SOLITAIRE (2012), TREVO…..

•68/M, DM, HTN, CAD, underwent PTCA to LAD•Admitted for surgery of aortic stenosis.•Double anti-platelets was stopped•Patient developed acute onset right side weakness with aphasia.

IV- tPA given, no improvement

Procedure time 28-minutes

Patient made complete neurological recovery next day

Case 2

41 y.o. male

Stroke in sleep

Left sided weakness with facial palsy

NIHSS 14

Last well seen at 10:30 PM

Presented to emergency at 5:08 AM (six and half hours after)

5:14AM

5:23AM

6:22AM

8:07AM

Patient made gradual recovery

Left LL 4/5 and UL 3/5

Improved by 30 day follow up

Results Total No. of patients= 42 (M-19, F- 23)

Time of arrival: 30 min- 840 min (mean 203.8 minutes)

NIHSS at admission: 5-22 (Mean 14.33)

MVO 39, IV tPA- 19

Good recanalization(TICI 2b or 3) in 57.1%

mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)

Recanalization V/s Outcome

Mechanical recanalization in acute stroke

LVO, IV tPA C.I./not -effective

Stent retrievers – good recanalization; < 1-hr

Case selection and speed are crucial

Previous trials failed (older devices, delay, case selection)

IMS III – subanalysis- CTA guided cases-significant benefit

Many randomized trials going on…..answer in few years

Clinical-

Bleeding

Seizures

Neurological deficit

Headaches

Incidental

Cerebral Arteriovenousmalformations

AVM- treatment options

Embolization

Radiosurgery (GK, LINAC, Cyberknife)- Dr Aditya Gupta

Surgery – Dr AN Jha, Dr Aditya Gupta

EmbolizationGlue (NBCA) vs Onyx embolization

Neurosurgery 2006

AVMs- multimodality treatment

Small ruptured- Embo/Sx, RS

Small unruptured- RS, Embo, Sx

Large- Embo, RS

Dural AVFs- Embo

Spinal AVMs- Embo, Sx

Medanta Stroke & Neurovascular team

Vascular neurology, Neurointervention, Neurosurgery, Neurocritical care, Vascular imaging, rehabilitation

Stroke

TIAs (preventive)

SAH-aneurysms

ICH

AVMs

NeurointerventionTeam at Medanta

•Round the clock

•Integrated team

• Fellowship

•Academics -

Publications

STROKE AND NEUROVASCULAR INTERVENTIONS FOUNDATION

Newsletter

Interesting case studies via social media

Updates regarding treatment protocols

Stroke training course for physicians

Advanced stroke and neurointervention simulator courses

You tube channel

Opinion regarding cases via tablets/smart phones