Disclosure. Advances in Interventional Neurology. Disclosure. Natural History of Disease 3/15/2018. Vishal B. Jani MD

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1 Advances in Interventional Neurology Disclosure Vishal B. Jani MD Medical Director Vascular Neurology Consultant Interventional Neurology CHI Health Assistant Professor, Creighton University School of Medicine Omaha, NE. Disclosure Natural History of Disease 5 th cause of morbidity and mortality 1 stroke every 40 seconds $ 41 billion burden Large artery occlusion mortality 60 to 90 % 1

2 Vascular Anatomy Each Minute 1.9 million neurons loss Stroke Treatment before 1990s 1983 to 1996 Intravenous Thrombolysis Urokinase. Fundamentals of Clot and tpa mechanism of action Streptokinase. Tissue plasminogen activator. 2

3 Safety / Success 6% : Bleed 30% :Success - small clot 20% 3% : Success - large clot 3% Embolectomy 101 Intra arterial Tissue plasminogen activator Devices Mercy Device 3

4 YEAR 1996 to YEAR 2013 YEAR 1996 to YEAR 2015 IMS III MR-RESCUE SYNTHESIS EXPANSION Eligible patients who Patients with largevessel, Patients within 4.5 anterior- had received IV rt-pa hours after symptom within 3 hours after circulation occlusion within 8 hours after onset Endovasc IV rt-pa Endovasc Standard Endovasc IV rt-pa only only IMS III MR-RESCUE SYNTHESIS EXPANSION Eligible patients who Patients with largevessel, Patients within 4.5 anterior- had received IV rt-pa hours after symptom within 3 hours after circulation occlusion within 8 hours after onset Endovasc IV rt-pa Endovasc Standard Endovasc IV rt-pa only only A report from the Working Group of International Congress of Interventional Neurology. J Vasc Interv Neurol May;7(1): A report from the Working Group of International Congress of Interventional Neurology. J Vasc Interv Neurol May;7(1): Summary of trials: clinical outcome at 3 months 1996 to 2015 mrs 0-2 IMS III MR-RESCUE SYNTHESIS EXPANSION Endovasc IV rt- Endovasc Standard Endovasc IV rt- PA only PA only 43% 40% 38% 61% 42% 46% Endovascular treatment remains UNPROVEN A report from the Working Group of International Congress of Interventional Neurology. J Vasc Interv Neurol May;7(1): Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) Re: N Engl J Med 2015;372: Re: Published on February 11, 2015, at NEJM.org.. 4

5 IMS III, MR CLEAN, and ESCAPE trials PA within 3 hours after Endovasc IV rt-pa only IMS III MR-CLEAN ESCAPE Eligible patients who Patients with largevessel, Patients with small had received IV rt- anterior- infarct core +anterior circulation occlusion circulation occlusion+ within 6 hours moderate-to-good after collaterals within Endovasc Standard 12 hours after Endovasc Standard IMS III versus MR CLEAN versus ESCAPE Clinical outcome at 3 months IMS III MR-CLEAN Endovasc Control Endovasc Control mrs 33% 30% % 30% Devices to treat acute ischemic stroke patients with arterial occlusion New generation stent retrievers Case examples New generation stent retrievers: FDA approval in 2012 SOLITAIRE Merci stent Retriever Retriever Stent Retriever Merci Retriever Clot Removal Sucess 61% 24% 86% 60% Independent Functionality 58% 33% 58% 22% Saver JL, Lancet. 2012;380: Nogueira RG. Lancet 2012;380:

6 How Safe is Interventional stroke Procedure? With in 6 hours Symptom atic ICH MR-CLEAN Endo-vasc Control ESCAPE Endo-vasc Control 7.7% 6.4% 3.6% 2.7% Re: N Engl J Med 2015;372: Re: N Engl J Med 2013;368: American Heart Association/American Stroke Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke: (Stroke. 2013;44: ) Patients eligible for intravenous rt PA should receive intravenous rt PA even if IA treatments are being considered. IA fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours duration caused by occlusions of the MCA Class I; Level of Evidence A Class I; Level of Evidence B 2015 American Heart Association/American Stroke Association Focused Update (Stroke. 2015; 46: ) Patients eligible for intravenous rt PA should Class I; receive intravenous rt PA even if IA treatments Level of Evidence A are being considered. Patients should receive endovascular therapy with a stent retriever if: a.prestroke mrs score 0 to 1, b.receiving intravenous r-tpa<4.5 hrs, c.causative occlusion of the ICA or proximal MCA (M1). d.age 18 years, e.nihss score of 6, Class I; Level of Evidence A DAWN AND DIFFUSE 3 trials 2018 DAWN Patients with small infarct core +anterior circulation occlusion within 6-16 hours after Endovasc Medical DIFFUSE Patients with small infarct core +anterior circulation occlusion within 6 to 24 hours after Endovasc Medical 6

7 IMS III versus MR CLEAN versus ESCAPE Clinical outcome at 3 months IMS III MR-CLEAN DIFFUSE mrs 0-2 Endovasc Control Endo- Control vasc 33% 6% 60% 30% Endo- Control vasc 44% 8% How Safe is Interventional stroke Procedure? 2015 MR-CLEAN ESCAPE With in 6 hours Symptom atic ICH Endo-vasc Control Endo-vasc Control 7.7% 6.4% 3.6% 2.7% 2018 DAWN DIFFUSE 3 6 to 24 hours Endo-vasc Control Symptom atic ICH 6% Endo-vasc Control NA NA Re: N Engl J Med 6% 2015;372: Re: N Engl J Med 2013;368: American Heart Association/American Stroke Association Focused Update (Stroke. 2018; 49) In selected patients with AIS within 6 to 16 Level of hours of last known normal who have LVO in the Evidence A anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended. In selected patients with AIS within 6 to 24 Class I; Level of hours of last known normal who have LVO in the Evidence B anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable Class II ; 7

8 Neuro-Intervention Team Procedures Performed by Neuro-Intervention team Carotid Stenting Thrombectomy for large vessel stroke Brain aneurysm Brain AVM/DAVM Presurgical tumor embolization Carotid Stenting Epistaxis Embolization Traumatic head/neck vascular lesions Epistaxis Embolization Traumatic head/neck vascular lesions 8

9 Brain aneurysm Conclusions STROKE CAN BE TREATED TIME IS BRAIN MAGNITUDE OF MINIMALLY INVASIVE EUROENDOVASCULAR PROCEDURES ARE AVILABLE AND ARE FIRST CHOICE OF TREATMENT. Thank you. Vishal Jani MD