What is a Stent

Retriever?:The New Stroke

Guidelines

Tony JosephPGY3

HAEMR

Disclosures….I wish….

OBJECTIVES• What options exist after IV TPA?

• What is IA therapy? What is a stent retriever?

• What's the rush to get the MRA?

• When to transfer for endovascular therapy?

2013

MR RESCUEIMS III

SYNTHESIS

SYNTHESIS• Prospective Randomized Open Blinded End Point

(PROBE)

Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.

SYNTHESIS• PROBE

• TPA eligible with in 4.5hrs

• IA with in 6hrs

• 14% stent retrievers

• mRS 0-1, death at 3 months, sICH at 7 days

Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.

362 patients

NCHCT

IV TPA

IA TPAMechanical Clot

Disruption

Modified Rankin Score

http://www.neuroems.com/2014/06/17/stroke-the-survivor/

SYNTHESIS• PROBE

• TPA eligible with in 4.5hrs

• IA with in 6hrs

• 14% stent retreivers

• mRS 0-1, death at 3 months, sICH at 7 days

Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.

362 patients

NCHCT

IV TPA

IA TPAMechanical Clot

Disruption

IMS III• Prospective Randomized Open Blinded End Point

(PROBE)

IMS III• PROBE• NIHSS ≥ 10• Sx onset w/ in 5hrs

• 1.5% stent retrievers

• mRS 0-2, death at 90 days

656 patients

IV TPA with in 3 hours

CT

IV TPA

onlylow dose TPA

and/orIA TPA/DeviceBroderick JP, Palesch YY, Demchuk AM, et al; Interventional Management of

Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke.

N Engl J Med. 2013;368(10):893-903.

IMS III• PROBE• NIHSS ≥ 10• CTA added on

later• 1.5% stent

retrievers• mRS 0-2, death

at 90 days

656 patients

IV TPA with in 3 hours

CT

IV TPA only low dose TPAand/or

IA TPA/Device

MR RESCUE• Prospective Randomized Open Blinded End Point

(PROBE)

MR RESCUE• PROBE

• 118 patients

• CT/MRI

• large artery stroke with favorable penumbra

• MERCI / PENUMBRA

• optional IA TPA

Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914-923.

MR RESCUE• PROBE

• 118 patients

• CT/MRI

• large artery stroke with favorable penumbra

• MERCI / PENUMBRA (wine cork screw)

• optional IA TPA

Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914-923.

2015

MR CLEANESCAPE

SWIFT PRIME REVASCAT

EXTEND IA

MR CLEAN• PROBE

• 500 patients

• NIHSS ≥ 2

• Proximal anterior circulation stroke w/ in 6 hrs

• CTA/MRA/DSA

• mRS score 0-2 improved significantly

• 81% stent retrievers

Usual Care

Usual Care+

IA TPA and/ormechanical thrombectomy

STENT RETRIEVERS

http://directorsblog.nih.gov/2015/03/10/clot-removal-impressive-results-for-stent-retrievers-in-acute-stroke/

http://directorsblog.nih.gov/2015/03/10/clot-removal-impressive-results-for-stent-retrievers-in-acute-stroke/

https://www.strykerneurovascular.com/products/ais/trevo-xp-provue-retriever-4x20mm

ESCAPE

ESCAPE• PROBE

• 316 patients

• NIHSS > 5

• CTA

• randomized up to 12 hours after sx onset

• 86% stent retrievers

IV TPA with in 4.5 hours

IV TPA + endovascular tx (stent retrievers)

http://thehappyhospitalist.blogspot.com/2012/11/Should-I-Become-An-ICU-Nurse-someecard-Humor-Explains-Why.html

MR CLEANESCAPE

SWIFT PRIME REVASCAT

EXTEND IA

SWIFT PRIME

SWIFT PRIME

IV TPA with in

4.5 hours

IV TPA + endovascular tx (stent retrievers)

196 patients

NIHSS 8-29

CTA or MRA w/ ICA or M1 occlusion

• 100% of both groups got TPA

• 89% stent retrievers

MR CLEANESCAPESWIFT PRIME REVASCAT

EXTEND IA

EXTEND IA

EXTEND IA• PROBE

• 70 pts

• CT or MR

• Perfusion studies required

• ICA, M1, or M2 occlusion visualized

• 100% of both groups got TPA

EXTEND IA• IV TPA vs. IV TPA + stent retriever

• groin puncture with in 6hrs and complete by 8hrs

• Outcome was reperfusion at 24 hrs AND

• mRS 0-1 at day 3

• 8pt reduction in NIHSS

• no sICH difference

MR CLEANESCAPESWIFT PRIME REVASCAT

EXTEND IA

REVASCAT

REVASCAT

IV TPA

IV TPA + thrombectomy with stent retriever

• mRS 0-2 at 90 days improved

• no sICH difference

206 pts up to age 85

NIHSS ≥ 6

ICA or M1 occlusion

No improvement after 30 minutes of TPA

MR CLEANESCAPESWIFT PRIME REVASCAT

EXTEND IA

MR CLEANESCAPESWIFT PRIME REVASCAT

EXTEND IA

Badhiwala, J H. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA: Journal Of The American Medical Association Volume: 314 Issue: 17 (2015-11-03) p. 1832-1843. ISSN: 0098-7484

More trials to come…

• THERAPY• THRACE• DAWN• POSITIVE

The NNT

Class 1; Level A Evidence

•Give the IV TPA•Then get a CTA (or MRA)•Refer to endovascular therapy if (rule of 6)•18 years or older (duh!)•prestroke mRS 0 or 1•got TPA with in 4.5 hours• ICA or M1 occlusion (no M2)•NIHSS at least 6•ASPECTS at least 6•groin puncture with in 6 hours

•Stent retrievers preferred over MERCI

ASPECTS?• Alberta Stroke

Programe Early CT Score

• 10 is normal NCHCT

• lose points for involvement of MCA territory

• Score 8-10 likely to benefit from TPA

• Score of 7 or less is bad

Class IIA; Level C

• If TPA contraindicated, may consider endovascular with stent retriever

Class IIB; Level C

• After 6 hours, it’s a gamble to do endovascular

• longer time trials pending

• Advanced imaging (perfusion) benefits beyond CTA/MRA are unknown

Class IIB; Level C

• Forget the studies and go anywhere M2, M3, ACA, vertebral, basilar, or posterior cerebral arteries

• if sx within 6 hours

• Go nuts on kids too

Class IIB; Level B-R

• If they have clot at ICA or M1 clot but fit none of the rule of 6 except for time, go nuts

Class III; Level B-R

• Do not wait for the TPA to work, like REVASCAT trial did, got straight to endovascular therapy

What about IA TPA?

• r-TPA is not FDA approved for this

• Doseage?

• Use for carefully selected pts (Class I; Level B-R)

• even if iv r-TPA is contraindicated (Class IIB; Level C)

• Use a stent retriever instead (Class I; Level E)

EMS System• Acute Stroke Ready Hospitals

(ASRH)

• Primary Stroke Center (PSC)

• Comprehensive Stroke Center (CSC)

• Primary centers should consider getting a CTA/MRA to decide on transferring Class IIB; Level C

http://www.jointcommission.org/assets/1/18/StrokeProgramGrid_abbr_AHA-TJC_5-1-15.pdf

Rare Events

• 4% of patients receive TPA

• Less than 1% receive endovascular therapy

Adeoye O, Albright KC, Carr BG, et al. Geographic access to acute stroke care in the United States. Stroke. 2014;45(10):3019–3024.

CASE TIME• DC is a 60yoM who

presents with left sided weakness, symptom onset 40 minutes ago, NIHSS 8, CT and CTA show M1 occlusion. Should we give TPA?

• Should we recommend thrombectomy with a stent retriever?

DS is 64yoM p/w NIHSS 10Sx started 3 hours agoCT w/ ASPECTS 8TPA GivenNearest CSC is 4 hours away. Do you…

A. Get CTAB. Transfer DSC. Wait for the TPA to

workD. Admit to the ICU

• DD is a 65yoM who presents with weakness that started 4 hours ago and NIHSS 7, CT neg for hemorrhage.

• TPA?

• CTA shows M3 stroke, endovascular therapy referral?

Special thanks to help from….

Dr. Raghu Seethala

Dr. Joshua Goldstein

Dr. Thabele Leslie-Mazwi

Stroke Models Physicians (DC, DS, DD)