program faculty disclosures i have no relevant financial ... · 1996 when the fda approved...
TRANSCRIPT
Interventional Management of Acute Ischemic Stroke
Charles Anthony Bruno, Jr., D.O.
Attending Interventional Neuroradiologist
Jefferson Radiology
Hartford Hospital
Program Faculty Disclosures
I have no relevant financial relationships to disclose
I will not discuss products in my presentation
- Ischemic stroke is the leading cause of disability and fifth leading cause of
mortality in the US
- Approximately 800,000 strokes occur in the US each year - roughly one stroke
every 40 seconds
- Estimated direct and indirect cost of stroke care is over $100 billion a year
- Despite the magnitude of problem there was therapeutic nihilism for patients with
acute ischemic stroke for centuries
Background
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- First major breakthrough in treatment of acute ischemic stroke (AIS) came in
1996 when the FDA approved intravenous tissue plasminogen activator (IV-
tPA) for use within 3 hours of symptom onset - created paradigm shift in
management of acute ischemic stroke
- Approval came following completion of a NINDS trial showing tPA improved
functional outcome at 90 days in AIS when administered within 3 hours of
symptom onset
IV-tPA
- Since the approval of IV-TPA there have been multiple randomized controlled
trials, including ECASS III, demonstrating efficacy of IV-tPA up to 4.5 hours
from symptom onset
- Limitations of IV-tPA include limited treatment window (within 4.5 hours) and
low recanalization rates for large-vessel occlusions (M1, carotid terminus,
cervical ICA)
IV-tPA
- The major drivers for the development of endovascular stroke therapy were the
desire to expand the 3-hour treatment window and the relatively low
recanalization rates for large-vessel occlusions with IV-tPA (which often caused
the most severe strokes)
- The evolution of endovascular procedures for AIS started with use of a plethora
of techniques including intra-arterial (IA) thrombolysis, mechanical manipulation
of clot with microwires and microcatheters, and percutaneous angioplasty / stents
Endovascular Therapy
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- In early 2000 physicians at UCLA developed and patented a corkscrew-like
retrieval device designed to retrieve lost endovascular coils accidentally released
into the cerebral vasculature-soon became apparent that the device could be
used for removal of endoluminal thrombi
- In 2004 the Mechanical Embolus Removal in Cerebral Ischemia (MERCI)
retriever became the first device approved for clot removal in acute ischemic
stroke - unfortunately limited recanalization rates
Endovascular Therapy
MERCI Retriever
Type to enter a caption.
- Second generation devices include the stentrievers, Solitaire and Trevo, and
aspiration catheters
- These newer generation devices have been shown to have significantly better,
≤90%, recanalization rates compared with the MERCI retriever
Endovascular Therapy
Stentrievers Clot engaged in stentriever
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Endovascular Therapy
Aspiration catheters and suction devices
- So… Does endovascular
therapy work?
Endovascular Therapy
YES!!
Endovascular Therapy
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- Beginning in December 2014, a series of pivotal trials were published
demonstrating that endovascular thrombectomy (EVT) was highly effective:
- MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke
- ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke
- EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection
- SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.
- REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke
- THRACE investigators. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after
stroke (THRACE)
- More recent studies have shown safety and benefit of mechanical thrombectomy
up to 24 hours after symptom onset - DAWN / DEFUSE trials
Endovascular Therapy
Non-contrast head CT
Right CCA
Early ischemic change
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Type to enter a caption. Type to enter a caption.
Basilar artery
Thank You
Questions?
References
1. Jayaraman MV, Hussain MS, Abruzzo T, et al. Embolectomy for stroke with emergent large vessel
occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of
NeuroInterventional Surgery. J Neurointerv Surg 2015;7:316–21.doi:10.1136/neurintsurg-2015-
011717
2. Gandhi CD, Al Mufti F, Singh IP, et al. Neuroendovascular management of emergent large vessel
occlusion: update on the technical aspects and standards of practice by the Standards and Guidelines
Committee of the Society of NeuroInterventional Surgery. J Neurointerv Surg 2018;10:315–
20.doi:10.1136/neurintsurg-2017-013554
3. Pride GL, Fraser JF, Gupta R, et al. Prehospital care delivery and triage of stroke with emergent large
vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of
Neurointerventional Surgery. J Neurointerv Surg 2017;9:802–12.doi:10.1136/neurintsurg-2016-012699
4. Mokin M, Pendurthi A, Ljubimov V, et al. ASPECTS large vessel occlusion, and time of symptom
onset: estimation of eligibility for endovascular therapy. Neurosurgery 2018;83:122–7
5. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute
ischemic stroke. N Engl J Med 2015;372:11–20.doi:10.1056/NEJMoa1411587
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