European Stroke intervention Guidelines

ESMINT/ESO/ESNR/EAN

WLNC 2015

C. CognardUniversity Hospital of Toulouse

France

Recent burning news • October 2014, World Stroke Conference (Istanbul):

Mr Clean +

• Nov. 2014, ESO- Karolinska stroke update conference,

ESO, ESMINT/ESNR guidelines meeting

• Feb. 2015, International Stroke conference, Nashville:

Escape, Extend IA, Swift Prime +

• Feb. 2015, Stroke winter school

ESO, ESMINT/ESNR guidelines meeting

• Apr. 2015, European Stroke Organization conference (Glasgow)

Thrace and Revascat +

mRs 2 at 3MMT / IV in all studies

Odds ratio: 2.29

MortalityMT / IV in all studies

Odds ratio: 0.74

All symptomatic ICHsMT / IV in all studies

Odds ratio: 1.14

Writing recommendations is doing diplomacy

Need to obtain a common agreement

Treatment recommendations

Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to

6h after onset

What means “up to 6h after onset” ?Angio-room ?

Groin?Recanalization ?

Onset MT OnsetIV

OnsetGroin

DelayIV/Groin

Mr Clean < 6 h 1h25 4h20 2h55

Escape < 12 h 1h50 3h05 1h15

Extend IA < 6 h 2h07 3h30 1h23

Swift Prime < 6 h 1h50 3H04 1h14

Revascat < 8 h 1h57 4h29 2h32

Thrace < 6 h 2h32 4h15 1h43

Therapy < 5 h 1h48 3h46 1h58

Studies Design/Results

Onset to reperfusion in Mr Clean

• Median 332 mn (IQR 279-394)– 1.5% < 3h– 22% from 3 to 4.5h– 40% from 4.5 to 6h– 37% > 6h

• MT/IV Absolute risk difference on mRS 0-2– At 2h: 33 %– At 6h: 6.5%– 7% decrease per hour delay

Thrombectomy is recommended up to 6h after onset

Treatment recommendations

Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to

6h after onset

What means a “LVO of the anterior circulation”?

LVO ?

Should we treat stroke with ICA occlusion / Severe stenosis?

ICA/M1/M2 Cervical ICA

Mr Clean 28/62/8 % 32 %

Escape 28/68/4% 12.7 %

Extend IA 31/57/11% -

Swift Prime 18/68/14 % 4.3%

Revascat 25/85/10% -

Thrace 15/85%BA: 0.5%

-

Therapy 33/56/11 % -

Studies Results

MR Clean

LVO ?

Should we treat M2 occlusion?

ICA/M1/M2

Mr Clean 28 / 62 / 8 %

Escape 28 / 68 / 4 %

Extend IA 31 / 57 / 11%

Swift Prime 18 / 68 / 14 %

Revascat 25 / 85 / 10 %

Thrace 15 / 85 / 0 %

Therapy 33 / 56 / 11 %

Studies Results

Treatment recommendations

One messageSave time

Treatment recommendations

Evidence only concerns stent-retrievers

Door is open to other device/technique

But need evaluation

Treatment recommendations

Thrombectomy is recommended as first line treatment in case IV is

contraindicated

IV Other

Mr Clean 89%

Escape 72.7%

Extend IA 100%

Swift Prime 100%

Revascat 68% Failure IV 30 min

Thrace 100% Failure IV 60 min

Therapy 100%

Studies Design

Treatment recommendations

Thrombectomy can be performed in the posterior circulation

But NO Evidence

ICA/M1/M2 Cervical ICA

Mr Clean 28/62/8 % 32 %

Escape 28/68/4% 12.7 %

Extend IA 31/57/11% -

Swift Prime 18/68/14 % 4.3%

Revascat 25/85/10% -

Thrace 15/85%BA: 0.5%

-

Therapy 33/56/11 % -

Studies Results

Treatment recommendations

Thrombectomy must be done by comprehensive neurovascular team

Treatment recommendations

And by highly specialized Neuro-interventionists

What are the National / International requirements ?

Treatment recommendations

There is no Evidence

% GA

Mr Clean 37.8%

Escape 9.1%

Extend IA 36%

Swift Prime 37.1%

Revascat 6.7%

Thrace 50%

Therapy

GA versus CS

Impact of GA on TT effect in Mr CleanCommon adjusted OR

• Effect of GA/non GA on 3M shift mRS– Non GA vs Control: 2.13 R (95% CI, 1.46-3.11)– GA vs Control: 1.09 (95% CI, 0.69-1.71)

• Effect of GA/non GA on 3M mRS 0 -2– Non GA vs Control: 2.79 (95% CI, 1.70-4.59)– GA vs Control: 1.09 (95% CI, 0.56-2.12)

A randomize Trial

• One answer to one question

• Statistical massage to answer a not predefined question should not be done

Need for randomized Trials design to answer the question GA/CS

Patient Selection

No thrombectomy if no LVO

Patient Selection

Do we need to assess the LVO by imaging To decide to transfert the patient to a

thrombectomy center ?

But lot of patient un-necessarily transferred for a deep hematoma

Patient Selection

The major question!

Which patient should not receive

thrombectomy due to a too large stroke?

NIHSSDesign

NIHSSIV/MT

ASPECTDesign

ASPECTIV/MT

Other imaging

Mr Clean > 1 18/17 all 9/9

Escape > 5 17/16 > 5 9/9 Multiphase CTA

Extend IA 0-42 13/17 - « Rapid » mismatch:

Swift Prime 8-29 17/17 9/9

Revascat ≥ 6 17/17 > 6 CT> 5MR

7

Thrace 10 - 25 17/18 > 6

Therapy > 8 18/17 7.5

Studies Design

MR Clean

MR Clean

On Which imaging criteria we should refuse to perform a thrombolysis ?

And why?

Is thrombectomy dangerous?

Or just futile

Patient Selection

- 1/3 MCA: No

- ASPECT: No

- Volume of diffusion by automated software: Yes but which volume?

- Rapid mismatch ?

Patient Selection

No age limit

But be human!

MR Clean

Recommendations for implementation, registries and further trial

We need to do politics

Recommendations for implementation, registries and further trial

Recommendations for implementation, registries and further trial

RCTs for:-Posterior circulation ?- Stroke imaging ?

- IV+MT versus MT alone +/- IV +- GA versus CS +++

- > 6h +++- New devices +++

After 6 H?

Down study

GA/CS?

Recommendations for implementation, registries and further trial

A national consecutive registry in every country

The routine practice in Toulouse

• We have treated in the last week:– A 91 YO Woman– A Patient with a NIHSS 2– Lot of patients with M2 occlusion– Lot of patients with ICA occlusion– No patient > 6h

Thanks