Mechanical Thrombectomy in Acute Ischemic Stroke Michel Elias … · 2018. 2. 13. · Michel Elias Mawad, M.D. Neurological Institute . TIMELY ANTEGRADE REPERFUSION < 6 HOURS PHARMACOLOGICAL

Mechanical Thrombectomy in Acute Ischemic Stroke

Michel Elias Mawad, M.D.

Neurological Institute

TIMELY ANTEGRADE REPERFUSION

< 6 HOURS

PHARMACOLOGICAL

IV. r-TPA

MECHANICAL

THROMBECTOMY THROMBO- ASPIRATION

Have several advantages over pharmacologic thrombolysis and may be used as primary or adjunctive strategies.

• Provide faster recanalization.

• Lessen and may even preclude the use of chemical thrombolytics, in this manner very likely reducing the risk of ICH.

• Possible to extend the treatment window beyond the limit of 6–8 hours (T occlusion of ICA or basilar artery thrombosis).

• More efficient at coping with material resistant to enzymatic

degradation (white organized clots in atrial fibrillation).

• Fragmenting a clot increases the surface area accessible to fibrinolytic agents and allows inflow of fresh plasminogen, which, in turn, may increase the speed of thrombolysis.

MECHANICAL REVASCULARZATION PROCEDURES

1) Mechanical thromboaspiration 2) Mechanical Thrombectomy

SUCTION THROMBECTOMY





MECHANICAL THROMBECTOMY


Mechanical thrombectomy using

stenttriever


Thrombectomy using stenttriever














OUTCOME

• MANDATORY USE OF CTA/MRA FOR IDENTIFICATION OF PROXIMAL VESSEL

OCCLUSION

• USE OF LATEST GENERATION DEVICES (STENT TRIEVERS)

• OUTCOME SIMILAR IRRESPECTIVE OF GENDER

• OUTCOME SIMILAR IRRESPECTIVE OF AGE

• THROMBECTOMY WAS BENEFICIAL IN MORE PROXIMAL THEN DISTAL

OCCLUSION (ICA BIF. > M1 OCCLUSION > M 2 OCCLUSION)

• THROMBECTOMY WAS BENEFICIAL DESPITE EXTRACRANIAL ICA

OCCLUSION

• THROMBECTOMY WAS BENEFICIAL WITH OR WITHOUT IV r-TPA

Mechanical Thrombectomy in Acute Stroke

1

hr

2

hr 3

hr

4

hr

5

hr

6

hr

IV r-TPA GROIN

PUNCTURE

STENT TRIEVER

DEPLOYMENT ONSET OF

SYMPTOMS

1 2 3 4 5 6 7 8 9 1

0

11 1

2

ONSET OF

SYMPTOMS

HOURS

TIME WINDOW FOR GROIN PUNCTURE / CLOT ACCESS


TRIAL MR

CLEAN

ESCAPE EXTEND IA SWIFT

PRIME

REVASCAT

TIME TO EVT <6 HR. < 12 HR. <6 HR. <6 HR. <8 HR.

ASPECTS 9 9 NR 9 7-8

IV TPA 87% 73% 100% 100% 68%

TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’

STENTTRIEVER 81% 86% 100% 100% 100%

MRS 0-2

ABS.

IMPROVMT.

32.6%

13.5%*

53%

23.7%*

71.4%

31.4%*

60%

24.7%*

15.5%*

TICI 2b/3 58% 72% 86% 88% 65%

EVT IA TX. IA TX. SOLITAIRE SOLITAIRE SOLITAIRE

NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17

SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%


TRIAL MR

CLEAN


PRIME

REVASCAT



IV TPA 87% 73% 100% 100% 68%

TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’

STENTTRIEVER 81% 86% 100% 100% 100%

MRS 0-2

ABS.

IMPROVMT.

32.6%

13.5%*

53%

23.7%*

71.4%

31.4%*

60%

24.7%*

15.5%*

TICI 2b/3 58% 72% 86% 88% 65%


NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17

SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%


TRIAL MR

CLEAN


PRIME

REVASCAT



IV TPA 87% 73% 100% 100% 68%

TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’

STENTTRIEVER 81% 86% 100% 100% 100%

MRS 0-2

ABS.

IMPROVMT.

32.6%

13.5%*

53%

23.7%*

71.4%

31.4%*

60%

24.7%*

15.5%*

TICI 2b/3 58% 72% 86% 88% 65%


NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17

SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%


TRIAL MR

CLEAN


PRIME

REVASCAT



IV TPA 87% 73% 100% 100% 68%

TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’

STENTTRIEVER 81% 86% 100% 100% 100%

MRS 0-2

ABS.

IMPROVMT.

32.6%

13.5%*

53%

23.7%*

71.4%

31.4%*

60%

24.7%*

15.5%*

TICI 2b/3 58% 72% 86% 88% 65%


NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17

SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%


TRIAL MR

CLEAN


PRIME

REVASCAT



IV TPA 87% 73% 100% 100% 68%

TIME TO GROIN 260 ‘ 241’ 210’ 224’ 269’

STENTTRIEVER 81% 86% 100% 100% 100%

MRS 0-2

ABS.

IMPROVMT.

32.6%

13.5%*

53%

23.7%*

71.4%

31.4%*

60%

24.7%*

15.5%*

TICI 2b/3 58% 72% 86% 88% 65%


NIHSS 17 - 18 16 - 17 17 - 13 17 - 17 17 - 17

SYMPT. ICH I/C 7.7%/6.4% 3.6%/2.7% 0%/5.7% 0%/3.1% 1.9%/1.9%


12:OO NOON 3:00 PM 6:00 PM


In Summary,

• Use IV r-TPA in all eligible

patients

• Avoid large volume infarcts

• Obtain CT & CTA to exclude

hemorrhage and to identify

large vessel occlusion

• Initiate Mechanical

Thrombectomy early, ideally

within 4 hours from onset of

symptoms

• Mandatory use of latest

generation devices

• Refer NIHSS > 10 to

Comprehensive Stroke Center

1. Give aspirin

2. Give heparin

3. Give tPA

4. Give tPA AND proceed to endovascular

treatment

5. Do not give tPA BUT proceed to endovascular

treatment

What is your Management Plan?

Emergency cerebral arteriogram

Emergency cerebral arteriogram






Documents

Mechanical Thrombectomy in Acute Ischemic Stroke Michel Elias … · 2018. 2. 13. · Michel Elias Mawad, M.D. Neurological Institute . TIMELY ANTEGRADE REPERFUSION < 6 HOURS PHARMACOLOGICAL