neurointervention in hemorrhagic and ischaemic stroke
TRANSCRIPT
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
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Stroke training course for physicians
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