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European Stroke intervention Guidelines
ESMINT/ESO/ESNR/EAN
WLNC 2015
C. CognardUniversity Hospital of Toulouse
France
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Recent burning news • October 2014, World Stroke Conference (Istanbul):
Mr Clean +
• Nov. 2014, ESO- Karolinska stroke update conference,
ESO, ESMINT/ESNR guidelines meeting
• Feb. 2015, International Stroke conference, Nashville:
Escape, Extend IA, Swift Prime +
• Feb. 2015, Stroke winter school
ESO, ESMINT/ESNR guidelines meeting
• Apr. 2015, European Stroke Organization conference (Glasgow)
Thrace and Revascat +
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mRs 2 at 3MMT / IV in all studies
Odds ratio: 2.29
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MortalityMT / IV in all studies
Odds ratio: 0.74
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All symptomatic ICHsMT / IV in all studies
Odds ratio: 1.14
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Writing recommendations is doing diplomacy
Need to obtain a common agreement
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Treatment recommendations
Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to
6h after onset
What means “up to 6h after onset” ?Angio-room ?
Groin?Recanalization ?
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Onset MT OnsetIV
OnsetGroin
DelayIV/Groin
Mr Clean < 6 h 1h25 4h20 2h55
Escape < 12 h 1h50 3h05 1h15
Extend IA < 6 h 2h07 3h30 1h23
Swift Prime < 6 h 1h50 3H04 1h14
Revascat < 8 h 1h57 4h29 2h32
Thrace < 6 h 2h32 4h15 1h43
Therapy < 5 h 1h48 3h46 1h58
Studies Design/Results
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Onset to reperfusion in Mr Clean
• Median 332 mn (IQR 279-394)– 1.5% < 3h– 22% from 3 to 4.5h– 40% from 4.5 to 6h– 37% > 6h
• MT/IV Absolute risk difference on mRS 0-2– At 2h: 33 %– At 6h: 6.5%– 7% decrease per hour delay
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Thrombectomy is recommended up to 6h after onset
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Treatment recommendations
Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to
6h after onset
What means a “LVO of the anterior circulation”?
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LVO ?
Should we treat stroke with ICA occlusion / Severe stenosis?
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ICA/M1/M2 Cervical ICA
Mr Clean 28/62/8 % 32 %
Escape 28/68/4% 12.7 %
Extend IA 31/57/11% -
Swift Prime 18/68/14 % 4.3%
Revascat 25/85/10% -
Thrace 15/85%BA: 0.5%
-
Therapy 33/56/11 % -
Studies Results
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MR Clean
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LVO ?
Should we treat M2 occlusion?
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ICA/M1/M2
Mr Clean 28 / 62 / 8 %
Escape 28 / 68 / 4 %
Extend IA 31 / 57 / 11%
Swift Prime 18 / 68 / 14 %
Revascat 25 / 85 / 10 %
Thrace 15 / 85 / 0 %
Therapy 33 / 56 / 11 %
Studies Results
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Treatment recommendations
One messageSave time
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Treatment recommendations
Evidence only concerns stent-retrievers
Door is open to other device/technique
But need evaluation
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Treatment recommendations
Thrombectomy is recommended as first line treatment in case IV is
contraindicated
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IV Other
Mr Clean 89%
Escape 72.7%
Extend IA 100%
Swift Prime 100%
Revascat 68% Failure IV 30 min
Thrace 100% Failure IV 60 min
Therapy 100%
Studies Design
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Treatment recommendations
Thrombectomy can be performed in the posterior circulation
But NO Evidence
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ICA/M1/M2 Cervical ICA
Mr Clean 28/62/8 % 32 %
Escape 28/68/4% 12.7 %
Extend IA 31/57/11% -
Swift Prime 18/68/14 % 4.3%
Revascat 25/85/10% -
Thrace 15/85%BA: 0.5%
-
Therapy 33/56/11 % -
Studies Results
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Treatment recommendations
Thrombectomy must be done by comprehensive neurovascular team
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Treatment recommendations
And by highly specialized Neuro-interventionists
What are the National / International requirements ?
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Treatment recommendations
There is no Evidence
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% GA
Mr Clean 37.8%
Escape 9.1%
Extend IA 36%
Swift Prime 37.1%
Revascat 6.7%
Thrace 50%
Therapy
GA versus CS
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Impact of GA on TT effect in Mr CleanCommon adjusted OR
• Effect of GA/non GA on 3M shift mRS– Non GA vs Control: 2.13 R (95% CI, 1.46-3.11)– GA vs Control: 1.09 (95% CI, 0.69-1.71)
• Effect of GA/non GA on 3M mRS 0 -2– Non GA vs Control: 2.79 (95% CI, 1.70-4.59)– GA vs Control: 1.09 (95% CI, 0.56-2.12)
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A randomize Trial
• One answer to one question
• Statistical massage to answer a not predefined question should not be done
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Need for randomized Trials design to answer the question GA/CS
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Patient Selection
No thrombectomy if no LVO
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Patient Selection
Do we need to assess the LVO by imaging To decide to transfert the patient to a
thrombectomy center ?
But lot of patient un-necessarily transferred for a deep hematoma
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Patient Selection
The major question!
Which patient should not receive
thrombectomy due to a too large stroke?
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NIHSSDesign
NIHSSIV/MT
ASPECTDesign
ASPECTIV/MT
Other imaging
Mr Clean > 1 18/17 all 9/9
Escape > 5 17/16 > 5 9/9 Multiphase CTA
Extend IA 0-42 13/17 - « Rapid » mismatch:
Swift Prime 8-29 17/17 9/9
Revascat ≥ 6 17/17 > 6 CT> 5MR
7
Thrace 10 - 25 17/18 > 6
Therapy > 8 18/17 7.5
Studies Design
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MR Clean
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MR Clean
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On Which imaging criteria we should refuse to perform a thrombolysis ?
And why?
Is thrombectomy dangerous?
Or just futile
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Patient Selection
- 1/3 MCA: No
- ASPECT: No
- Volume of diffusion by automated software: Yes but which volume?
- Rapid mismatch ?
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Patient Selection
No age limit
But be human!
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MR Clean
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Recommendations for implementation, registries and further trial
We need to do politics
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Recommendations for implementation, registries and further trial
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Recommendations for implementation, registries and further trial
RCTs for:-Posterior circulation ?- Stroke imaging ?
- IV+MT versus MT alone +/- IV +- GA versus CS +++
- > 6h +++- New devices +++
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After 6 H?
Down study
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GA/CS?
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Recommendations for implementation, registries and further trial
A national consecutive registry in every country
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The routine practice in Toulouse
• We have treated in the last week:– A 91 YO Woman– A Patient with a NIHSS 2– Lot of patients with M2 occlusion– Lot of patients with ICA occlusion– No patient > 6h
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Thanks