MEET 2007: Evaluation and treatment of the stroke and TIA patient for the non-neurointerventionist. neurointerventionist

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1 MEET 2007: Evaluation and treatment of the stroke and TIA patient for the non-neurointerventionist neurointerventionist Steve Ramee, MD Ochsner Medical Center New Orleans

2 DISCLOSURE Nothing Nothing to disclose.

3 Percentage Breakdown of Deaths from Cardiovascular Diseases United States: 2001 Source: CDC/NCHS. p5

4 Age-Adjusted Death Rates for Coronary Heart Disease, Stroke, and Lung and Breast Cancer for White and Black Females United States: 2001 Source: CDC/NCHS. p7

5 Don t hurt my brain, its my second favorite organ. Woody Allen

6 Birth of a Neurointervention Program: 1994 Carotid bifurcation is causative in less than 1/3 of all TIA s and strokes! Other lesion locations do not have established surgical therapy: Aorto-ostial ostial stenosis Subclavian stenosis Vertebrobasilar disease Intracranial stenosis PFOPFO Atrial Atrial fibrillation These patients need treatment, too!

7 Each specialty has deficiencies Cardiologists lack a fund of knowledge. Neuroradiologists lack clinical skills. Neurologists lack angiographic skills. Neuroradiology FUND OF KNOWLEDGE Neurology or Neurosurgery ANGIO SKILLS CLINICAL SKILLS CARDIOLOGY

8 Ochsner Multidisciplinary Neurovascular Team Components Emergency Medicine Stroke Stroke Neurology Radiology Interventional Neuroradiology Non-invasive Cardiology Interventional Cardiology Internal Internal Medicine Vascular Vascular Surgery Physical Physical Medicine

9 What they do with Stroke and TIA patients ER Physicians Dx/triage TIA & stroke Stroke neurology Clinical evaluation/tcd Initiate stroke therapy Referral for intervention Radiology CFD/CT/MRI Neuroradiology Angiography Intracranial intervention Vascular Surgery Elective CEA Non-invasive cardiology Echocardiogram/TEE Critical care service Interventional cardiology Intracranial intervention Stroke intervention Carotid/veertebral stents PFO/ASD/LAA closure Internal Medicine Inpatient service Physical Medicine Rehabilitation

10 Major Types of Stroke Ischemic = 83% Hemorrhagic = 17%

Embolic occlusion rather than intracranial plaque rupture

11 What causes ischemic stroke? Different than MI. The intracranial vessels are usually normal. Embolic occlusion rather than intracranial plaque rupture Extracranial sources in 85%: Carotid plaque Cardioembolic Atrial appendage LV thrombus PFO Carotid dissection

12 Normal cerebral anatomy ACA: Lower extremity MCA: Upper extremity, speech Lenticulo-striate arteries ACA M1 M2 ICA Anterior Lateral

13 Normal Vertebral Artery Symptoms Dizziness Gait disturbances Blurred or double vision Syncope All brainstem functions Thalamoperforator a.

14 ANATOMY

15 Localization Simplified Cerbral cortex Nearly always Embolic Aphasia Neglect Visual Field Loss Hemiplegia Sensory Loss

16 Localization Simplified Lacunar cerebral Nearly always Thrombotic Pure Motor Hemiplegia Pure Sensory Mixed Motor Sensory Ataxic Hemiparesis No cortical signs

17 Localization Simplified Brainstem Embolic or Thrombotic Diplopia Nausea/Vomiting Crossed Findings Vertigo

18 We Aren t Doing Very Well: Managing Acute Stroke Patients 97% 97% of all stroke patients get NO therapy at all! 97% 97% of all stroke lawsuits are for non- treatment, NOT bad outcomes! 63% of stroke patients arrive at hospital > 24 hours after symptom onset! From Alberta, MJ et al. Stroke 1992;23:

19 In Our ER s: IV Lytics are ONLY effective if given within 3 hrs of symptom onset! Up to 90 min 2.8x better outcomes than placebo 90min - 3 hrs 1.5x better than placebo Over Over 3 hrs M 1 occlusion Multiple failed trials Poor outcome w/ i.v. lysis Marler et al. Neurology. 2000;55:

20 Or in Our Neuro-Intervention Suites: Intra-arterial Thrombolysis Prolyse in Acute Cerebral Thromboembolism (PROACT) II 180 patients with occlusion of middle cerebral artery within 6 hours of onset Recanalization Intraarterial Prourokinase (9mg) vs placebo Follow-up 3 months Pro-urokinase Placebo 66% 18% Hemorrhagic transformation 10% 2% Favorable outcome 40% 25%

21 Health Economics Hospital charges for Stroke Patients Stroke patients who receive a thrombolytic agent have significantly higher in-hospital charges but are currently small in number Of all discharges in DRGs 14 & 15 N (% of Total) LOS Mean Std. Charges Mean Patients receiving a thrombolytic identified by code ,452 (0.76%) 7.1 $31,765 99% get NO Rx! Patients not receiving a thrombolytic 321,757 (99.24%) 5.6 $16,400 Source: 2003 Medicare MedPAR data. Thrombolytic patients coded with ICD-9 code

22 Technique of Stroke Intervention

23 Catheter-based approach Time Time is brain Target Target vessel angiography first Other vessels only if dx is in question Cross Cross lesion with hydrophilic wire If soft thrombus: Lysis, balloon, stent If hard thrombus: Merci, balloon, stent Remember: Primum non-nocere nocere!

24 Acute Stroke Intervention 39 year old woman Mother of 4 yo boy Sudden collapse in shower at 5AM Dense R hemiplegia, aphasia CT showed MCA sign What would YOU do?

28 Four days later...

29 Concentric Retrieval System

30 12 RESULTS: NIH Stroke Scale 25 Patients with Acute Hemiplegic Stroke Ramee et al, Stroke, May 2004 Presentation versus 30 day outcome 13.3 P = Baseline 30 days

31 RESULTS: Modified Rankin Score 25 Patients with Acute Hemiplegic Stroke Ramee et al, Stroke, May 2004 Baseline versus 30 day outcome P = Baseline 30 days

32 What about Stroke Prevention?

33 What About Stroke Prevention? It s much easier than treatment! TIA is an ominous warning sign. Many patients have no warning TIA. Must treat underlying conditions that predispose to stroke.

The Heart and Aortic Arch as a Source of Preventable Ischemic Stroke Aortic arch and vertebral ostial stenosis ~25% ~15% Thrombotic IC cerebral and vertebral

34 The Heart and Aortic Arch as a Source of Preventable Ischemic Stroke Aortic arch and vertebral ostial stenosis ~25% ~15% Thrombotic IC cerebral and vertebral stenosis Cardioembolic Atrial fibrillation Akinetic segment Mitral stenosis Prosthetic valve Myxoma Cardiomyopathy ~25% ~30% Cryptogenic > 50-70% with PFO and ASD

35 IBNA\Folders\A\ATRITECH\BOLT\PPS\ 0210_0392_IBNA\main\ 0210_0392_IBNA_SCAtrial fibrillation source of stroke is a MAJOR Up to 25% of all ischemic strokes occur in patients with AF Percent of total strokes attributable to atrial fibrillation 35% 30% 25% 20% 15% 10% 5% 0% Source: Stroke, 1991, 22(8): Age group (years) Patients with AF have, on average, 5 to 6 times greater probability of having a stroke and 18 times greater probability of an embolic event 35% of patients with AF who are not treated with anticoagulants will have a stroke in their lifetime An estimated 55% of AF patients require anticoagulation therapy due to risk of stroke

36 Atrial Fibrillation and Stroke WATCHMAN Device by Atritech RCT 300 PTS 2:1 Randomization Atritech vs.. Warfarin

37 Frustration: Cryptogenic Stroke Antiquated historical term Pts with no carotid disease or afib 50-70% RA have a PFO! LA RA PRA Confirmed by TCD, TEE with bubble study LA PLA On Valsalva, PRA > PLA

Recurrence Rates on Medical Therapy in Cryptogenic Stroke 17% Stroke or death @ 2 yr!

38 Recurrence Rates on Medical Therapy in Cryptogenic Stroke 17% Stroke or 2 yr!! WARSS study NIH funded RCT 2606 patients randomized to ASA or Warfarin Excluded other sources of stroke (Afib, carotid dz.) Recurrent event = stroke or death at 2 years. Warfarin group 17.8% Aspirin group 16.0% Mohr et al, NEJM 2001, vol 345, 1444.

39 Remember our young mother with MCA occlusion?

40 Four days later... One month later, PFO closure

41 What about symptomatic intracranial stenosis?

42 How effective is medical Rx? WASID Trial NEJM 2005;352,

43 WASID Trial Double blind, Multicenter RCT 569 patients with TIA or Stroke 50-99% stenosis by angiography Warfarin (INR 2-3) 2 vs.. ASA 1300mg Primary 2years: Ischemic Stroke Brain Hemorrhage Death (non-neurologic, neurologic, vascular) NEJM 2005;352,

44 Two Year Stoke and Death 22% NEJM 2005;352,

45 PTA result

46 Elective Intracranial Intervention Freedom from events at one year 100% 80% 60% 40% 20% N = 26 patients 100% Neurologic evaluation 100% 93% 0% TIA Stroke Ramee et al, CCI 52: , 467, 2001

47 Who can prevent it? Neurologists Neuro-radiologists Neurosurgeons Cardiologists Radiologists Vascular Surgeons Internists TIA and Stroke It s up to All Of US at this meeting and our colleagues to prevent strokes They aren t referred to a neurologist until AFTER they have had one!

48 SUMMARY Stroke is a medical emergency. High morbidity, mortality, and cost Second only to CAD 85% of all strokes are embolic. 25% Atrial fibrillation 30% Cryptogenic 30% Atheroembolic Stroke patients are best managed by a multidisciplinary team. Interventional cardiologists are well suited to participate and provide stroke intervention. Stroke prevention much easier than stroke treatment and is our responsibility!

49 STROKE

Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine

Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine Institute The Oregon Clinic Disclosure I declare that neither