Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack
Clot Extraction Devices - cumming.ucalgary.ca · Stroke CT Angiography Renal Safety A Krol et al....
Transcript of Clot Extraction Devices - cumming.ucalgary.ca · Stroke CT Angiography Renal Safety A Krol et al....
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Clot Extraction Devices
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MERCI TrialStroke 2005;36:1432-1440
Big strokes
Proximal disease
3-8 hr time window
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MERCI TrialStroke 2005;36:1432-1440
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MERCI Recanalization
4 38 59
40 28 32
Recovery
Independent Dependent Death
recan n=85
Non-recan n=56
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Successful Revascularization by Number of Passes
18% 26%
36% 44%
46% 48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st pass 2nd pass 3rd pass 4th pass 5th pass 6th pass
Stroke 2005;36:1432-1440
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Unusual SAH Bleeding with Device
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Mechanical Devices
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Multi-MERCI
L5 system
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Multi-MERCI
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Multi-MERCI
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Multi-MERCI
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Multi-MERCI Recanalization
10 38 52
49 26 25
Recovery
Independent Dependent Death
recan n=112
Non-recan n=52
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Multi-MERCI Safety
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Terminal ICA Occlusion and MERCI
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Rescue ia therapy
iv tPATCDCTA
MFV 58cm/secMFV 21 cm/sec
DSAia tPA
MERCI
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Rescue ia therapy
iv tPA
CTADSA
ia tPA
MERCI
STOP
Same or worse
Primary Stroke CenterComprehensive Stroke Center
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IMS-3 Trial
Start iv tPA –0.09 mg/kg bolus
Start IV t-PA – 0.51 mg/kg infusion over 30 min, 60 mg max
Consent and randomize to one of 2 arms if eligible during this time frame
Angiography
Prox target thrombus
IV tPA 0.3 mg/kg over
final 30 minutes
Stop
IA Therapy: 2 mg-distal, 2 mg-intraclot,
9 mg/hr x 2 hrs, 22 mg max.)
No clot
– stop
NIHSS >10, < 3 hours
2/7 <2 hours, 1:1 randomization NIHSS 10-19
2:1 randomization NIHSS > 20, n=900
IV tPA alone IV+IA/mechanical
Up to 1 FDA approved Mechanical device
for clot extraction/lysis
At neurointerventionalist discretion
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Choice of Imaging is when and how bad decision?
Time from onset0 1h 2h 3h 6h 12h 24h 48h 72h ….Severe m
od resolving TIA
Deficit
vs
SPEEDDoor to CT scan <30 minutes
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Quote Thrombolysis not a panacea for stroke. New Engl J Med 1997.
“We think that patients are better served by accurate diagnosis and appropriate specific therapy than by a shotgun approach.”
“Vascular imaging tests are now widely available that can safely and quickly identify occlusive thrombi, and so ensure specificity.”
“Vascular and brain imaging should always precede thrombolysis.”
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CT bolus techniques
NCCT CTA Perfusion CT
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Stroke CT Angiography Renal Safety A Krol et al. Stroke (abstract) ASA 2005
481 patients had stroke CTA.
None of these patients developed acute renal failure needing dialysis.
3.1 % of patients fulfilled the criteria for RCN (>25% in their creatinine levels) .
Patients who underwent emergent CTA without knowledge of creatinine, 2/93 developed RCN.
49 patients received an additional DSA and none of these developed subsequent RCN.
14/144 had a >25% in their creatinine levels at long term follow-up.
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CT Angiography Reconstructions
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CTA coronal reformats
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CTA sagittal & oblique reformats
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When are the CT bolus techniques critical for hyperacute disabling stroke
decision making?
Very early scans with high suspicion of intracranial occlusion
NCCT underestimates infarct size
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Choice of Imaging is when and how bad decision?
Time from onset0 1h 2h 3h 6h 12h 24h 48h 72h ….Severe m
od resolving TIA
Deficit
vs
SPEED and SELECTION for iv/ia
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8 miles40 miles
vs
CT scanner
Local hospitalNo CT scanner
70 miles
Helical or multislice CT scanner 24h/365d coveragePrimary Stroke Center
170 miles
intraclot lysis
Interventional Facilities-interventional neurorad, neurosurgery
Comprehensive Stroke Center
ICH evacuation
vs
vs
Early ICA revascularization
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Basilar Artery Prognosis
Length of thrombusLOC at presentation
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pc-ASPECTS
Pn2
RPCA LPCARC LC
Mb2
RT LT
LCRC
Mb2
RPCA LPCALCRC
RT LT
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Basilar artery occlusion and tPAdichotomized by pc-ASPECTS
0 33 67
50 25 25
Recovery
Independent Dependent Death
pc-ASPECTS
8-10 n=16
0-7 n=15
n=31 basilar occlusions
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Sweet Spot for tPA; bNIHSS 6-20
4.6% “truly symptomatic ICH” in NINDS
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< 3 Hours from onset NINDS tPA Trial baseline NIHSS <
5 Parts A and B
81 19
79 7 12 2
Recovery
Complete Incomplete Poor Death
Placebo
rt-PA
n=58 NNH = 7!!!
2% sympt ICH