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How to be successful in

mechanical stroke managementtips and tricks

L.N. Hopkins, MD

University at Buffalo Neurosurgery

Distinguished Professor

State University of New York

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Keys to SuccessSave the Penumbra

Early Dx and TxTime is Brain

Medical management: BP, Statins, Antiplatelet, etc

Imaging: Brain viability (Go/No Go)

Analogy = STEMI(Get the artery OPEN!)-Minimize risk of intervention

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Time Is Brain

Save the Penumbra

Rapid Reperfusion May Reduce Neurologic Deficit

Reperfusion of the ischemic penumbra may reduce the extent of

damage and improve recovery

Timing is critical

The average patient loses 32,000 brain cells/second

ischemicpenumbra

core ischemic

zone

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Steps for successful stroke

intervention

Patient selection process:

CT: R/O hemorrhage

CTA: Clot location, arch anatomy, vessel tortuosity

CT perfusion: Physiological imaging for screening Selection of devices:

Guide catheters: large/flexible (Neuron, Revasc)

Stent-retrievers, Penumbra (aspiration), both, ..

Periprocedural care: Conscious sedation

General anesthesia for poorly cooperating patientsor with respiratory compromise

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Mechanical Clot RetrievalEvolution of acute stroke trials

Retrospective case reports and case series

Prospective single-arm studies

(MERCI, Multi-MERCI, Penumbra Pivotal Trial)

Randomized trials

(SWIFT, TREVO, IMS III)

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Evolution of Endovascular Stroke

Devices

StentsMerci Penumbra Stentreivers ???

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Stent-retrievers available

StenTrievers

Solitaire AB y FR Trevo /Trevo Pro IRIIS

Capture LP

Opticell

REVIVE pRESET Aperio

Pulse Separator 3D ReCOVER

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Solitaire - Covidien

CHARACTERISTICS:

- CE Mark : AB 2007, FR 2009

- Advantages: detachable, parametric design

(multiple planes of clot contact)

- Disadvantages: self detachment,

- 4 Available sizes

- Detachable: Yes(AB), No(FR)

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40mm Total Length

20mm Retrieval Area10mm TaperedArea

10mm Tapered

Area

Trevo and Trevo Pro (Stryker)-The device

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3D Penumbra Device

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Does using newer devices make a

difference? Yes!

Review of prospective

stroke trials showed

improvement in

revascularization from

1995 to 2012

JNIS2012 Fargen et al

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Does choosing the right device

make a difference? Yes!

Example: Randomized trials comparing different types of

thrombectomy devices

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Data from trials vs real-world experience

ENRG group data

-Early post-market experience with stent-

retrievers (Solitaire FR) in post-FDA

approval era-101 patients from 10 centers throughout

the US

-A variety of other approaches are used inconjunction with Solitaire FR

thrombectomy

Neurosurgery2012, Mokin et al. Under revision

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Combined aspiration + stentriever

thrombectomy approach

1. Stent-retriever engages

the thrombus

2. The stent-retriever is

retracted into aspirationcatheter under

continuous suction

Dumont et al.,JNIS, Submitted

C bi d i i

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Aspiration

catheter

Stent-retriever

Step 1: Position

aspiration catheter

proximal to the

thrumbus

Step 2: Deploy the

stent-retriever

Combined aspiration + stent-

retriever thrombectomy approach

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Potential ProblemEmbolization to New Territory

1

1 Solitaire Retrospective Study. Presented at

WFITN, 2011.2 Trevo 2 Trial. Presented at ESC, 2012.

Better retrievers

Distal adjunctive suction Flow arrest/reversal

Prevention

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Advantages of the combined approach

1. Debris created with thrombectomy may

be aspirated, preventing distal

embolization2. Aspiration catheter also acts as a distal

access catheter, facilitating delivery of

stent-retriever to the target lesion

3. Aspiration alone may restore flow

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The Right Approach to StrokeTime and Physiology Based

1. Choosing the right device

2. Choosing the right patient

- Common criteria for IA intervention:NIHSS 8

Onset of symptoms 0-8 hrs

- CTPsignificant viable brainie. preserved CBV

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Reopening the Artery works ifNo Large Volume Deficit

--Q: Should every stroke with large-vessel

occlusion be treated with stent-retrievers?

- A: No, each stroke case should be analyzedindividually.

Reperfusion hemorrhage is an issue with

large volume deficit

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Perfusion-based patient selection

Patient 1: has penumbra and

likely to benefit from intervention

Patient 2: has volume loss(arrow) and no penumbra poor candidate for intervention

Example: two patients with left MCA occlusion

and same duration of stroke symptoms

CBV CBV

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Data in support of perfusion-based

patient selection

Turk et al, 2011:Based on CT perfusion selection,

similar rates of good functional outcome and ICH

were found in patients with 6 hr from

symptom onset to endovascular procedure

JNIS 2012. Turk et al.

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And more data in support of

perfusion for patient selection

- Utilization of CT perfusion imaging for patient

selection resulted in improved functional outcomes in

the recanalized population.

- Outcomes of CT perfusion group were compared to

MERCI, Multi-MERCI and the Penumbra trial results.

JNIS 2012. Rai et al.

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Tips and Tricks

Stroke Teamrapid triage and treatment

Imaging: CT, CTA CTP (Key=Volume)

-When to intervene (NIHSS; CTP)ToolsM-1 access catheters (5FR or larger)

Stentrivers, stents- capture and remove clot or

-Deploy stent permanently

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Gates Vascular Institute

1 Acre Floorplate

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Jacobs Institute Center for Innovation

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Thank you!

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Thank You