Acute Ischemic Stroke Imaging. Ronald L. Wolf, MD, PhD Associate Professor of Radiology
|
|
- Peter Holland
- 6 years ago
- Views:
Transcription
1 Acute Ischemic Stroke Imaging Ronald L. Wolf, MD, PhD Associate Professor of Radiology
2 Title of First Slide of Substance An Illustrative Case 2
3 Disclosures No financial disclosures Off-label uses of some products (e.g., bolus gadolinium perfusion) Some MR perfusion images created for display/educational purposes using PMA image analysis software (copyright owner: Kohsuke Kudo) provided by ASIST-JAPAN) or RAPID software for academic or research purposes and cannot be used for clinical evaluation. 3
4 Acute Ischemic Stroke (AIS) Imaging The basics Advanced imaging options Perfusion imaging in practice, yes or no? 4
5 Stroke Lay term for sudden loss of neurologic function ( brain attack ) Two major categories Ischemic (80-85%) Hemorrhagic (10-15%) Third largest cause of mortality, leading cause of morbidity in the US 5
6 Treatment Options Approved treatment IV tpa: infarct < 3 (4.5) hours Mechanical: Merci > Penumbra > Solitaire, Trevo (stent retrievers) <6 hours Off label IV tpa after 3 (4.5) hours, IA tpa < 6 hours (longer for basilar occlusion) Greatest benefit Low thrombus burden/small vessel, good collaterals, lack of extended infarct 6
7 TICI Grade Assessment of EVT technical outcome Modified thrombolysis in cerebral infarction (TICI) grade Grade 0: no antegrade perfusion Grade 1: perfusion past initial obstruction but limited distal branch filling with little or slow distal perfusion Grade 2: 2a: perfusion of < 50% of vascular distribution of occluded artery 2b: perfusion of 50% of vascular distribution of the occluded artery Grade 3: full perfusion with filling of all distal branches Grade 2b/3: better clinical outcome than 2a mrs 0-2: 49 vs 34% D/C home: 41 vs 17% Marks et al. JNIS 2014 Jayaraman et al. AJNR
8 Goals: Diagnostic Imaging in AIS At minimum: Exclude hemorrhage (and obvious non-stroke disorders) usually NECT, MRI if possible Evaluate location and extent of infarct/edema (e.g., > 1/3 MCA territory?) NECT or better DWI 8
9 Not AIS 9
10 Not AIS Chorea - Toxoplasmosis Pt. 1 Pt. 2 HA, MS - PRES Chorea - Toxoplasmosis HA, MS - PRES 10
11 Acute Aphasia, 2 hours from onset 11
12 Determinants of Outcome Symptom severity NIHSS>10 poor prognosis without successful treatment NIHSS<5 favorable Infarct core size > ml less favorable Arteries involved Basilar, proximal MCA, ICA less favorable Small branch, presence of collaterals favorable Treatment/recanalization Score (NIHSS) Stroke Severity 0 No Symptoms 0-4 Minor 5-15 Moderate Moderate to Severe Severe 12
13 Outcome: ASPECTS Alberta Stroke Program Early CT Score (ASPECTS) 10 point topographic CT score Quantify/score early ischemic changes ASPECTS 7 poor functional outcome and symptomatic hemorrhage Barber et al, Lancet 2000; 355; 1670 Hill et al, AJNR 2006; 27:1612 Hill et al. AJNR
14 Outcome: ASPECTS M1 C L I IC M2 M3 M4 M6 M5 ASPECTS = 2 (10-8) 14
15 Outcome: ASPECTS C L IC M1 I M2 M4 M5 M3 M6 15
16 Outcome: BASIS Boston Acute Stroke Imaging Scale (BASIS) Proximal occlusion on CTA or MRA (ICA, M1, M2, and/or basilar) major stroke (BASIS +) If no proximal occlusion, evaluation parenchyma with MR or CT ASPECTS 7 = major stroke (BASIS +) Others are minor stroke (BASIS -) 205 AIS patients, 16 with IV± IA tpa 149 minor, 56 major stroke Majority of BASIS + with poor outcome (death or discharge to rehab facility vs. discharge home) Torres-Mozqueda et al, AJNR 2008; 29: 1111 Fig. from González RG et al, PLoS One. 2012; 7(1): e
17 What next? LMCA syndrome, onset unclear RMCA syndrome, 6 hours out s/p IV rtpa 17
18 Goals: Diagnostic Imaging in AIS At minimum: Exclude hemorrhage (and obvious non-stroke disorders) Evaluate location and extent of infarct/edema (e.g., > 1/3 MCA territory?) Maximize benefit/risk - tissue clock : Accurate assessment of 4 P s Parenchyma, Pipes, Perfusion, Penumbra Target patients who will benefit most from treatment Extend treatment window Minimize risk Rowley, AJNR 2001; 22:
19 Acute Ischemic Syndrome The basics Advanced imaging options Parenchyma Pipes Perfusion Penumbra Perfusion imaging in practice, yes or no? 19
20 Parenchyma: CTA-SI ASPECTS Left MCA syndrome 20
21 Parenchyma: DWI DWI is the optimal method if feasible Only minimal reversibility for acute ischemic infarct Large DWI insult (>70mL) unfavorable with or without recanalization Small DWI insult more favorable, and with target perfusion mismatch more likely to benefit from recanalization 21
22 Parenchyma: DWI/FLAIR Mismatch DWI minutes FLAIR hours DWI+, FLAIR- For < 4.5 hr from symptoms Sens 62%, NPV 54% Spec 78%, PPV 83% Thomalla et al, Lancet Neurol
23 Infarct Patterns Embolic Embolic with fragmentation Small vessel Internal Watershed Watershed Vasculitis CP arrest HSV 1 23
24 Stroke? Left gaze preference, left sided weakness 24
25 Stroke? Left gaze preference, left sided weakness 25
26 Right Hemiparesis: Stroke? DWI FLAIR 26
27 Acute Ischemic Syndrome The basics Advanced imaging options Parenchyma Pipes Perfusion Penumbra Perfusion imaging in practice, yes or no? 27
28 Lateral Medullary (Wallenberg) Syndrome FLAIR DWI ADC 28
29 Pipes: MR Angiography Left vertebral artery dissection/occlusion 2D TOF MRA MIP 2D TOF MRA source images 29
30 Pipes: CT Angiography Left vertebral artery dissection/occlusion CTA: slab-mip 30
31 Pipes: Collaterals 31
32 32
33 Pipes: Collaterals, HVS on FLAIR Sluggish flow in poorly developed collaterals 33
34 Elderly Male, Collapsed, Locked In 34
35 Basilar Artery Occlusion DWI 3D TOF MRA 35
36 On Presentation 36
37 Vasculitis Right anterior circulation 37
38 3 Days Later 38
39 Watershed Infarct Traumatic Carotid Dissection 39
40 Carotid Dissection 40
41 Acute Ischemic Syndrome The basics Advanced imaging options Parenchyma Pipes Perfusion Penumbra Perfusion imaging in practice, yes or no? 41
42 Perfusion/Penumbra: AIS at 6 Hours Status post IV rtpa 42
43 Perfusion/Penumbra: AIS at 6 Hours Status post IV rtpa: occluded RICA and distal MCA, ACA branches 43
44 Perfusion/Penumbra: AIS at 6 Hours CTP: large infarct, small mismatch rcbf < 30% rcbv 40% TTP 5-6s Tmax > 5s 44
45 Perfusion/Penumbra: AIS at 8 Hours 45
46 Perfusion/Penumbra: AIS at 8 Hours Diffusion perfusion mismatch (penumbra) 46
47 Left MCA Occlusion 47
48 Acute Ischemic Syndrome The basics Advanced imaging options Parenchyma Pipes Perfusion Penumbra Perfusion imaging in practice, yes or no? 48
49 Perfusion and Penumbra Fig. from González RG JMRI 2012; 36: 252 González RG JMRI 2012; 36:
50 Penumbra Imaging IA rtpa and/or mechanical lysis better recanalization than IV rtpa alone Early recanalization associated with improved outcomes prior to irreversible injury Diffusion alone or perfusion/penumbra? 50
51 Perfusion Imaging in AIS Accurately assess dead vs. salvageable? Acute MCA occlusive disease (hours) Chronic MCA occlusive disease (days, weeks, months) 51
52 Value of Perfusion Imaging in AIS Stroke 2009; 40: 3646 Stroke 2010; 41: E25 52
53 Perfusion in AIS: Against Major strokes Most important is rapid ID of occlusion (CTA, MRA) and size of infarct (DWI) Core and penumbra not independent Collaterals link the two Minor strokes or TIA DWI small or none Mild symptoms, small vessel occlusion or partial compensation? Greater value PWI in this setting González RG JMRI 2012;36:259 53
54 Perfusion in AIS: For 54
55 Tissue Clock and Target Mismatch Dead versus salvageable DEFUSE 2 Target mismatch PWI(T max >6s)/DWI 1.8 DWI < 70mL PWI(T max >10s) < 100mL Mismatch volume > 15mL Target mismatch patients more favorable response with reperfusion OR 8.8 for favorable clinical response with reperfusion in target mismatch group OR 0.2 in no target mismatch group Lansberg et al, Lancet Neurology 2012; 11:
56 LMCA Syndrome, 6 hrs, NIHSS 30 56
57 LMCA Syndrome, 6 hrs, NIHSS 30 57
58 LMCA Syndrome, 6 hrs, NIHSS 30 CBF CBV MTT Tmax PMA image analysis software, provided by ASIST-JAPAN) 58
59 LMCA Syndrome, 6 hrs, NIHSS 30 Penumbra (pre) Penumbra (post) post DSA CT 59
60 NINDS tpa Trials IV r-tpa vs. placebo within 3 hours First proven/approved stroke treatment Neurologic recovery better with tpa (30% more likely to have minimal or no disability) Hemorrhage more likely (6.4% tpa vs. 0.6% placebo) Mortality similar at 3 months (17% tpa vs. 21% placebo) Limitations 22% present within 3 hours, and only 4% get tpa 51% ineligible (mild severity, med/surg history, etc) Sustained recanalization in only 13% Hemorrhage risk NEJM 1995; 333:
61 Acute Stroke Imaging after 2014 Prior to 2014 R-tPA only proven effective treatment for acute ischemic stroke After MR CLEAN ESCAPE EXTEND-IA SWIFT PRIME REVASCAT 61
62 Acute Stroke Imaging: Recent Trials 62
63 Where are we going? 6-16 hours Perfusion imaging 63
64 2015 AHA/ASA Updated EVT Guidelines Eligible patients should get IV tpa even if EVT considered (Class I, Level A) Should receive EVT with stent retriever if meeting following criteria (Class I, Level A) Pre-stroke mrs 0 to 1 IV tpa within 4.5 hours ICA/M1 occlusion Age at least 18 years NIHSS score at least 6 ASPECTS at least 6 Treatment initiated within 6 hours of onset Powers et al. Stroke
65 2015 AHA/ASA Updated EVT Guidelines TICI 2b/3 reperfusion as early as possible (Class I; Level of Evidence A), preferably within 6 hrs of onset (Class I; Level of Evidence B-R) Effectiveness of EVT initiated >6hrs of onset uncertain. Additional data needed. (Class IIb; Level of Evidence C) EVT, if completed within 6 hrs of onset, for selected pts with contraindication to IV TPA is reasonable. Additional data needed. (Class IIa; Level of Evidence C) EVT is reasonable for M2/M3, ACA, basilar, PCA in selected pts if initiated within 6 hrs of onset. Additional data needed. (Class IIb; Level of Evidence C) Powers et al. Stroke
66 Conclusions: AIS Imaging Need to: Exclude hemorrhage (and obvious non-stroke disorders) Evaluate location and extent of infarct/edema (e.g., > 1/3 MCA territory?) Want to address 4 P s : Parenchymal injury, Pipes, Perfusion, Penumbra Rationale is to improve safety, target patients who will benefit most from treatment (e.g., with tpa), extend treatment window Comments ronald.wolf@uphs.upenn.edu 66
67 Protocols Tissue Clock, not Ticking Clock Emergent MRI (~12min) DWI Fast FLAIR GRE Add-ons PWI (~1min) Fast 3D TOF of COW (< 5 min) 3D CE MRA Head and Neck (~1min) Emergent CT/CTA/CTP ~10-15 minutes Full MRI (~45min) Routine brain with/without contrast GRE DWI and PWI MRA 3D TOF of head 2D TOF neck 3D CE MRA neck Option: fat sat T1 neck 67
68 [Double text] 68
69 [single text] 69
Imaging Stroke: Is There a Stroke Equivalent of the ECG? Albert J. Yoo, MD Director of Acute Stroke Intervention Massachusetts General Hospital
Imaging Stroke: Is There a Stroke Equivalent of the ECG? Albert J. Yoo, MD Director of Acute Stroke Intervention Massachusetts General Hospital Disclosures Penumbra, Inc. research grant (significant) for
More informationThe DAWN of a New Era for Wake-up Stroke
The DAWN of a New Era for Wake-up Stroke Alan H. Yee, D.O. Stroke and Critical Care Neurology Department of Neurology University of California Davis Medical Center Objectives Review Epidemiology and Natural
More informationUpdate on Early Acute Ischemic Stroke Interventions
Update on Early Acute Ischemic Stroke Interventions Diana Goodman MD Lead Neurohospitalist Maine Medical Center Assistant Professor of Neurology, Tufts University School of Medicine I have no disclosures
More informationStroke Clinical Trials Update Transitioning to an Anatomic Diagnosis in Ischemic Stroke
Stroke Clinical Trials Update Transitioning to an Anatomic Diagnosis in Ischemic Stroke Alexander A. Khalessi MD MS Director of Endovascular Neurosurgery Surgical Director of NeuroCritical Care University
More informationUPDATES IN INTRACRANIAL INTERVENTION Jordan Taylor DO Metro Health Neurology 2015
UPDATES IN INTRACRANIAL INTERVENTION Jordan Taylor DO Metro Health Neurology 2015 NEW STUDIES FOR 2015 MR CLEAN ESCAPE EXTEND-IA REVASCAT SWIFT PRIME RECOGNIZED LIMITATIONS IV Alteplase proven benefit
More informationCT Perfusion is Essential for Stroke Triage. Maarten Lansberg, MD PhD Associate Professor of Neurology Stanford University, Stanford Stroke Center
CT Perfusion is Essential for Stroke Triage Maarten Lansberg, MD PhD Associate Professor of Neurology Stanford University, Stanford Stroke Center CT Perfusion is Essential for Stroke Triage Disclosures:
More informationEndovascular Treatment for Acute Ischemic Stroke: Curtis A. Given II, MD Co-Director, Neurointerventional Services Baptist Physician Lexington
Endovascular Treatment for Acute Ischemic Stroke: Curtis A. Given II, MD Co-Director, Neurointerventional Services Baptist Physician Lexington Disclosures: SWIFT PRIME site (Medtronic) Physician Proctor
More informationAdvances in Neuro-Endovascular Care for Acute Stroke
Advances in Neuro-Endovascular Care for Acute Stroke Ciarán J. Powers, MD, PhD, FAANS Associate Professor Program Director Department of Neurological Surgery Surgical Director Comprehensive Stroke Center
More informationBGS Spring Conference 2015
Neuroradiology in hyperacute stroke: what is the UK position? Dr Shelley Renowden Bristol NICE HIS July, 2013 The current evidence on mechanical clot retrieval for treating acute ischaemic stroke shows
More informationACUTE STROKE IMAGING
ACUTE STROKE IMAGING Mahesh V. Jayaraman M.D. Director, Inter ventional Neuroradiology Associate Professor Depar tments of Diagnostic Imaging and Neurosurger y Alper t Medical School at Brown University
More informationEndovascular Treatment Updates in Stroke Care
Endovascular Treatment Updates in Stroke Care Autumn Graham, MD April 6-10, 2017 Phoenix, AZ Endovascular Treatment Updates in Stroke Care Autumn Graham, MD Associate Professor of Clinical Emergency Medicine
More informationEndovascular Treatment of Ischemic Stroke
Endovascular Treatment of Ischemic Stroke William Thorell, MD Associate Professor Neurosurgery UNMC Co-Director Stroke and Neurovascular Center Nebraska Medicine Overview Definitions of terms Review basic
More information11/1/2018. Disclosure. Imaging in Acute Ischemic Stroke 2018 Neuro Symposium. Is NCCT good enough? Keystone Heart Consultant, Stock Options
Disclosure Imaging in Acute Ischemic Stroke 2018 Neuro Symposium Keystone Heart Consultant, Stock Options Kevin Abrams, M.D. Chief of Radiology Medical Director of Neuroradiology Baptist Hospital, Miami,
More informationAcute Stroke Treatment: Current Trends 2010
Acute Stroke Treatment: Current Trends 2010 Helmi L. Lutsep, MD Oregon Stroke Center Oregon Health & Science University Overview Ischemic Stroke Neuroprotectant trials to watch for IV tpa longer treatment
More informationMechanical thrombectomy beyond the 6 hours. Mahmoud Rayes, MD Medical Director, Stroke program Greenville Memorial Hospital
Mechanical thrombectomy beyond the 6 hours Mahmoud Rayes, MD Medical Director, Stroke program Greenville Memorial Hospital Disclosures None Worldwide statistics 1 IN 6 people will have a stroke at some
More informationIMAGING IN ACUTE ISCHEMIC STROKE
IMAGING IN ACUTE ISCHEMIC STROKE Timo Krings MD, PhD, FRCP (C) Professor of Radiology & Surgery Braley Chair of Neuroradiology, Chief and Program Director of Diagnostic and Interventional Neuroradiology;
More informationStroke Treatment Beyond Traditional Time Windows. Rishi Gupta, MD, MBA
Stroke Treatment Beyond Traditional Time Windows Rishi Gupta, MD, MBA Director, Stroke and Neurocritical Care Endovascular Neurosurgery Wellstar Health System THE PAST THE PRESENT 2015 American Heart Association/American
More informationMechanical thrombectomy in Plymouth. Will Adams. Will Adams
Mechanical thrombectomy in Plymouth Will Adams Will Adams History Intra-arterial intervention 1995 (NINDS) iv tpa improved clinical outcome in patients treated within 3 hours of ictus but limited recanalisation
More informationAcute Ischemic Stroke Imaging Innovations
Acute Ischemic Stroke Imaging Innovations Guilherme Dabus, MD, FAHA Director, Fellowship NeuroInterventional Surgery Miami Cardiac & Vascular Institute Baptist Neuroscience Center Baptist Neuroscience
More informationEndovascular Therapy: Beyond the Guidelines
Endovascular Therapy: Beyond the Guidelines Ashutosh P. Jadhav, MD PhD Assistant Professor, Neurology and Neurological Surgery Center for Neuro-endovascular Therapy UPMC Stroke Institute Pittsburgh, PA
More informationComparison of Five Major Recent Endovascular Treatment Trials
Comparison of Five Major Recent Endovascular Treatment Trials Sample size 500 # sites 70 (100 planned) 316 (500 planned) 196 (833 estimated) 206 (690 planned) 16 10 22 39 4 Treatment contrasts Baseline
More informationHow to Interpret CT/CTA for Acute Stroke in the Age of Endovascular Clot Retrieval
How to Interpret CT/CTA for Acute Stroke in the Age of Endovascular Clot Retrieval Peter Howard MD FRCPC Disclosures No conflicts to disclose How to Interpret CT/CTA for Acute Stroke in the Age of Endovascular
More informationEndovascular Treatment for Acute Ischemic Stroke
ular Treatment for Acute Ischemic Stroke Vishal B. Jani MD Assistant Professor Interventional Neurology, Division of Department of Neurology. Creighton University/ CHI health Omaha NE Disclosure None 1
More informationBackground. Recommendations for Imaging of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association
for Imaging of Acute Ischemic Stroke: A Scientific Statement From the American Heart Association An Scientific Statement from the Stroke Council, American Heart Association and American Stroke Association
More informationEndovascular Stroke Therapy
Endovascular Stroke Therapy Update with Emphasis on Practical Clinical and Imaging Considerations Sachin Kishore Pandey, MD, FRCPC Disclosures I have no relevant financial disclosures or conflict of interest
More information5/31/2018. Interventional Therapies that Expand Time Windows for Acute Ischemic Stroke Treatment. Disclosures. Impact of clot burden
Good Outcome (%) Rankin 0-2 at 90 days 5/31/2018 Interventional Therapies that Expand Time Windows for Acute Ischemic Stroke Treatment Disclosures Cerenovus: I am on Executive Committee for ARISE2 Trial
More informationAdvanced Neuroimaging for Acute Stroke
Advanced Neuroimaging for Acute Stroke E. Bradshaw Bunney, MD, FACEP Professor Department Of Emergency Medicine University of Illinois at Chicago Swedish American Belvidere Hospital Disclosures FERNE Board
More informationBroadening the Stroke Window in Light of the DAWN Trial
Broadening the Stroke Window in Light of the DAWN Trial South Jersey Neurovascular and Stroke Symposium April 26, 2018 Rohan Chitale, MD Assistant Professor of Neurological Surgery Vanderbilt University
More informationInterventional Treatment of Stroke
Interventional Treatment of Stroke Andrew F. Ducruet, MD Barrow Neurological Institute 2018 BNI Stroke Rehab Symposium October 13, 2018 Disclosures Consultant: Medtronic, Penumbra, Cerenovus Lecture Overview
More informationStroke Update Elaine J. Skalabrin MD Medical Director and Neurohospitalist Sacred Heart Medical Center Stroke Center
Stroke Update 2015 Elaine J. Skalabrin MD Medical Director and Neurohospitalist Sacred Heart Medical Center Stroke Center Objectives 1. Review successes in systems of care approach to acute ischemic stroke
More informationImaging Acute Stroke and Cerebral Ischemia
Department of Radiology University of California San Diego Imaging Acute Stroke and Cerebral Ischemia John R. Hesselink, M.D. Causes of Stroke Arterial stenosis Thrombosis Embolism Dissection Hypotension
More informationPerils of Mechanical Thrombectomy in Acute Asymptomatic Large Vessel Occlusion
Perils of Mechanical Thrombectomy in Acute Asymptomatic Large Vessel Occlusion Aman B. Patel, MD Robert & Jean Ojemann Associate Professor Director, Cerebrovascular Surgery Director, Neuroendovascular
More informationIMAGING IN ACUTE ISCHEMIC STROKE
IMAGING IN ACUTE ISCHEMIC STROKE Timo Krings MD, PhD, FRCP (C) Professor of Radiology & Surgery Braley Chair of Neuroradiology, Chief and Program Director of Diagnostic and Interventional Neuroradiology;
More informationDrano vs. MR CLEAN Review of New Endovascular Therapy for Acute Ischemic Stroke Patients
Drano vs. MR CLEAN Review of New Endovascular Therapy for Acute Ischemic Stroke Patients Peter Panagos, MD, FACEP, FAHA Associate Professor Emergency Medicine and Neurology Washington University School
More informationCase 1 5/26/2017 ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE
ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE Rhonda Whiteman Racing Against the Clock Workshop June 1, 2017 Objectives To discuss the hyperacute ischemic stroke management
More informationRBWH ICU Journal Club February 2018 Adam Simpson
RBWH ICU Journal Club February 2018 Adam Simpson 3 THROMBOLYSIS Reperfusion therapy has become the mainstay of therapy for ischaemic stroke. Thrombolysis is now well accepted within 4.5 hours. - Improved
More informationDisclosure. Advances in Interventional Neurology. Disclosure. Natural History of Disease 3/15/2018. Vishal B. Jani MD
Advances in Interventional Neurology Disclosure Vishal B. Jani MD Medical Director Vascular Neurology Consultant Interventional Neurology CHI Health Assistant Professor, Creighton University School of
More informationDisclosures. Current Management of Acute Ischemic Stroke. Overview. Focal brain ischemia. Nerissa U. Ko, MD, MAS Professor of Neurology May 8, 2015
Disclosures Current Management of Acute Ischemic Nerissa U. Ko, MD, MAS Professor of Neurology May 8, 2015 Nothing to disclose Research Funding: American Heart Association NIH/NINDS Selected slides courtesy
More informationWhat Have We Learned: Selection for Endovascular Stroke Therapy
What Have We Learned: Selection for Endovascular Stroke Therapy Raul G Nogueira, MD Associate Professor in Neurology, Neurosurgery, and Radiology Emory University Director, Neuroendovascular Service Director,
More informationMechanical Thrombectomy: Where Are We Now? T. Adam Oliver, MD Tallahassee Neurological Clinic Tallahassee, Florida TMH Neurosymposium June 11, 2016
Mechanical Thrombectomy: Where Are We Now? T. Adam Oliver, MD Tallahassee Neurological Clinic Tallahassee, Florida TMH Neurosymposium June 11, 2016 none DISCLOSURES Where did we come from? Spiotta, et
More informationACUTE ISCHEMIC STROKE. Current Treatment Approaches for Acute Ischemic Stroke
ACUTE ISCHEMIC STROKE Current Treatment Approaches for Acute Ischemic Stroke EARLY MANAGEMENT OF ACUTE ISCHEMIC STROKE Rapid identification of a stroke Immediate EMS transport to nearest stroke center
More informationCVA Updates Karen Greenberg, DO, FACOEP. Director Neurologic Emergency Department Crozer Chester Medical Center
CVA Updates 2018 Karen Greenberg, DO, FACOEP Director Neurologic Emergency Department Crozer Chester Medical Center Disclosure I have the following financial relationship with the manufacturer of any commercial
More informationEndovascular Neurointervention in Cerebral Ischemia
Endovascular Neurointervention in Cerebral Ischemia Beyond Thrombolytics Curtis A. Given II, MD Co-Director, Neurointerventional Services Baptist Physician Lexington 72 y/o female with a recent diagnosis
More informationEvidence for Mechanical ThrombectomyFor Acute Ischemic Stroke. Kenneth V Snyder MD PhD SUNY Buffalo, NY
Evidence for Mechanical ThrombectomyFor Acute Ischemic Stroke Kenneth V Snyder MD PhD SUNY Buffalo, NY Disclosure Speaker name:... I have the following potential conflicts of interest to report: Honorarium
More informationOn Call Guide to CT Perfusion. Updated: March 2011
On Call Guide to CT Perfusion Updated: March 2011 CT Stroke Protocol 1. Non contrast CT brain 2. CT perfusion: contrast 40cc bolus dynamic imaging at 8 slice levels ~ 60 sec creates perfusion color maps
More informationLatest Advances in the Neurointerventional Treatment of Ischemic Stroke P A C I F I C N E U R O. O R G
Latest Advances in the Neurointerventional Treatment of Ischemic Stroke Neurointerventional Management of Ischemic Stroke 1. Thrombectomy for acute ischemic stroke 2. Carotid artery stenting 3. Management
More informationframework for flow Objectives Acute Stroke Treatment Collaterals in Acute Ischemic Stroke framework & basis for flow
Acute Stroke Treatment Collaterals in Acute Ischemic Stroke Objectives role of collaterals in acute ischemic stroke collateral therapeutic strategies David S Liebeskind, MD Professor of Neurology & Director
More informationMechanical Thrombectomy of Large Vessel Occlusions Using Stent Retriever Devices
Mechanical Thrombectomy of Large Vessel Occlusions Using Stent Retriever Devices Joey English MD, PhD Medical Director, Neurointerventional Services California Pacific Medical Center Hospitals, San Francisco,
More informationUpdates on Endovascular Therapy
Updates on Endovascular Therapy 5 th Annual Intermountain Stroke Conference October 16, 2017 M. Shazam Hussain, MD, FRCP(C), FAHA Director, Cerebrovascular Center Associate Professor, CCLCM Staff, Vascular
More informationTitle: Stability of Large Diffusion/Perfusion Mismatch in Anterior Circulation Strokes for 4 or More Hours
Author's response to reviews Title: Stability of Large Diffusion/Perfusion Mismatch in Anterior Circulation Strokes for 4 or More Hours Authors: Ramon G. Gonzalez (rggonzalez@partners.org) Reza Hakimelahi
More informationPractical Considerations in the Early Treatment of Acute Stroke
Practical Considerations in the Early Treatment of Acute Stroke Matthew E. Fink, MD Neurologist-in-Chief Weill Cornell Medical College New York-Presbyterian Hospital mfink@med.cornell.edu Disclosures Consultant
More informationPlace for Interventional Radiology in Acute Stroke
Place for Interventional Radiology in Acute Stroke Dr Lakmalie Paranahewa MBBS, MD(Radiology), FRCR Consultant Interventional Radiologist Asiri Group of Hospitals Objectives Imaging in Stroke Neurovascular
More informationIV tpa and mechanical thrombectomy case selection
IV tpa and mechanical thrombectomy case selection 22 April 2017, 9.50-10.30 Deidre De Silva SGH campus, NNI, Singapore OUTLINE Reperfusion concept Case Selection factors IV tpa & Mechanical Thrombectomy
More informationInterventional Stroke Treatment
Interventional Stroke Treatment Vishal B. Jani MD Medical Director Vascular Neurology Consultant Interventional Neurology CHI Health Assistant Professor, Creighton University School of Medicine Omaha,
More informationCT INTERPRETATION COURSE
CT INTERPRETATION COURSE Refresher Course ASTRACAT October 2012 Stroke is a Clinical Diagnosis A clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal loss of cerebral
More informationDisclosure. + Outline. What is a stroke? Role of imaging in stroke Ischemic stroke Venous infarct Current topics
+ Kathleen R. Fink, MD University of Washington 5 th Nordic Emergency Radiology Course May 21, 2015 + Disclosure My spouse receives research salary support from: Bracco BayerHealthcare Guerbet Thank you
More informationAlex Abou-Chebl, MD Associate Professor of Neurology and Neurosurgery Director of Neurointerventional Services Director of Vascular and
Alex Abou-Chebl, MD Associate Professor of Neurology and Neurosurgery Director of Neurointerventional Services Director of Vascular and Interventional Neurology Fellowships University of Louisville School
More informationEndovascular Clot Retrieval. Teddy Wu Neurologist (and Stroke enthusiast) Christchurch Hospital
Endovascular Clot Retrieval Teddy Wu Neurologist (and Stroke enthusiast) Christchurch Hospital Something you can do tomorrow Melbourne half marathon 2016 In 2009 Simple approach to stroke - blocked artery,
More informationMechanical Endovascular Reperfusion Therapy
Get With the Guidelines Stroke Mechanical Endovascular Reperfusion Therapy February 1, 2017 Speaker Lee H. Schwamm, MD Executive Vice Chairman and Director of Stroke/TeleStroke Services, Department of
More informationAcute brain vessel thrombectomie: when? Why? How?
Acute brain vessel thrombectomie: when? Why? How? Didier Payen, MD, Ph D Université Paris 7 Département Anesthesiologie-Réanimation Univ Paris 7; Unité INSERM 1160 Hôpital Lariboisière AP-HParis current
More informationStroke Update. Lacunar 19% Thromboembolic 6% SAH 13% ICH 13% Unknown 32% Hemorrhagic 26% Ischemic 71% Other 3% Cardioembolic 14%
Stroke Update Michel Torbey, MD, MPH, FAHA, FNCS Medical Director, Neurovascular Stroke Center Professor Department of Neurology and Neurosurgery The Ohio State University Wexner Medical Center Objectives
More informationStrokecenter Key lessons of MR CLEAN study
Strokecenter Key lessons of MR CLEAN study Diederik Dippel Disclosures Funded by the Dutch Heart Foundation Nominal, unrestricted grants from AngioCare BV Medtronic/Covidien/EV3 MEDAC Gmbh/LAMEPRO Penumbra
More informationACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS. Justin Nolte, MD Assistant Profession Marshall University School of Medicine
ACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS Justin Nolte, MD Assistant Profession Marshall University School of Medicine History of Presenting Illness 64 yo wf with PMHx of COPD, HTN, HLP who was in
More informationSignificant Relationships
Opening Large Vessels During Acute Ischemic Stroke Significant Relationships Wade S Smith, MD, PhD Director UCSF Neurovascular Service Professor of Neurology Daryl R Gress Endowed Chair of Neurocritical
More informationDistal Mechanical Thrombectomy in Acute Ischemic Stroke Method and Benefit. Hans Henkes, Wiebke Kurre Stuttgart, Germany
Distal Mechanical Thrombectomy in Acute Ischemic Stroke Method and Benefit Hans Henkes, Wiebke Kurre Stuttgart, Germany 1 Thrombectomy... with stent-retrievers is an evidence based therapy for intracranial
More informationHistorical. Medical Policy
Medical Policy Subject: Mechanical Embolectomy for Treatment of Acute Stroke Policy #: SURG.00098 Current Effective Date: 01/01/2016 Status: Revised Last Review Date: 08/06/2015 Description/Scope This
More informationAMSER Case of the Month: March 2019
AMSER Case of the Month: March 2019 62 year-old male with left-sided weakness Ashley Graziano OMS IV, Lake Erie College of Osteopathic Medicine Erik Yannone MD, Charles Q. Li MD, Warren Chang MD, Matthew
More informationParameter Optimized Treatment for Acute Ischemic Stroke
Heart & Stroke Barnett Memorial Lectureship and Visiting Professorship Parameter Optimized Treatment for Acute Ischemic Stroke December 2, 2016, Thunder Bay, Ontario Adnan I. Qureshi MD Professor of Neurology,
More information1/19/2018. Endovascular Therapy for Stroke
Endovascular Therapy for Stroke 1 PROACT II (1999, IA urokinase)first to demonstrate benefit of EST Newer trials (including MERCI in 2005) demonstrated vessel recanalization but no clinical benefit 2 Based
More informationImaging in Stroke. D Nagaraja, N Karthik
Imaging in Stroke D Nagaraja, N Karthik Cerebro-vascular disease (stroke) is the second leading cause of death. Prior to CT era, diagnosis was essentially clinical supported by angio and lumbar puncture.
More informationSTATE OF THE ART IMAGING OF ACUTE STROKE
STATE OF THE ART IMAGING OF ACUTE STROKE Marin Penkov UH St Ivan Rilski Sofia RadiologyTogether 2-3 June 2017 GOALS The concept and significance of penumbra CT and MRI Basic Principles Clinical application
More informationCarotid artery stenting for long CTO and pseudo occlusion of carotid artery -2 case reports-
Carotid artery stenting for long CTO and pseudo occlusion of carotid artery -2 case reports- Katsutoshi Takayama, MD, Ph.D Department of Radiology and Interventional Neuroradiology Ishinkai Yao General
More informationSupplementary Online Content
Supplementary Online Content Badhiwala JH, Nassiri F, Alhazzani W, et al. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA. doi:10.1001/jama.2015.13767. etable 1. The modified
More informationFigures for Draft Response to IMS III, MR RESCUE, and SYNTHSESIS Trials
Figures for Draft Response to IMS III, MR RESCUE, and SYNTHSESIS Trials Figure 1: Lay Press Judgment May Belie a Deeper Examination of the Data. Truman ultimately defeated Dewey for the Presidency Subject
More informationEVOLUTION IN SYSTEMS OF STROKE CARE RIDWAN LIN, MD, PHD STROKE & INTERVENTIONAL NEUROLOGY BROWARD HEALTH
EVOLUTION IN SYSTEMS OF STROKE CARE RIDWAN LIN, MD, PHD STROKE & INTERVENTIONAL NEUROLOGY BROWARD HEALTH STROKE SYSTEMS OF CARE: 7. Secondary prevention 1. Primary prevention Patient 3. Emergency transport
More informationStroke: The First Critical Hour. Alina Candal, RN, PCC, MICN Kevin Andruss, MD, FACEP
Stroke: The First Critical Hour Alina Candal, RN, PCC, MICN Kevin Andruss, MD, FACEP Disclosures We have no actual or potential conflicts of interest in relation to this presentation. Objectives Discuss
More informationCode Stroke Intervention: Endovascular Therapies for Stroke J. DIEGO LOZANO MD INTERVENTIONAL NEURORADIOLOGY
Code Stroke Intervention: Endovascular Therapies for Stroke J. DIEGO LOZANO MD INTERVENTIONAL NEURORADIOLOGY Disclosures None Part A. Objectives Epidemiology of AIS and of ELVO Concept: Acute Ischemic
More informationFurther Pragmatic Trials of Thrombectomy are Needed
Further Pragmatic Trials of Thrombectomy are Needed Prof Keith W Muir Institute of Neuroscience & Psychology University of Glasgow Institute of Neurological Sciences Queen Elizabeth University Hospital
More informationAcute Stroke Management What is State of the Art?
Acute Stroke Management What is State of the Art? Karl-Titus Hoffmann Department of Neuroradiologie University of Leipzig / University Hospital Leipzig Disclosure Speaker name: Karl-Titus Hoffmann I have
More informationNeuro-vascular Intervention in Stroke. Will Adams Consultant Neuroradiologist Plymouth Hospitals NHS Trust
Neuro-vascular Intervention in Stroke Will Adams Consultant Neuroradiologist Plymouth Hospitals NHS Trust Stroke before the mid 1990s Swelling Stroke extension Haemorrhagic transformation Intravenous thrombolysis
More informationACUTE STROKE INTERVENTION: THE ROLE OF THROMBECTOMY AND IA LYSIS
Associate Professor of Neurology Director of Neurointerventional Services University of Louisville School of Medicine ACUTE STROKE INTERVENTION: THE ROLE OF THROMBECTOMY AND IA LYSIS Conflict of Interest
More informationLessons Learned from IMS III: Implications for the Future
Lessons Learned from IMS III: Implications for the Future Pooja Khatri, MD, MSc Professor, Dept of Neurology Director of Acute Stroke, UC Stroke Team University of Cincinnati Disclosures Univ of Cincinnati
More informationAnalysis of DWI ASPECTS and Recanalization Outcomes of Patients with Acute-phase Cerebral Infarction
J Med Dent Sci 2012; 59: 57-63 Original Article Analysis of DWI ASPECTS and Recanalization Outcomes of Patients with Acute-phase Cerebral Infarction Keigo Shigeta 1,2), Kikuo Ohno 1), Yoshio Takasato 2),
More informationAHA/ASA Guideline. Downloaded from by on November 7, 2018
AHA/ASA Guideline 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular
More informationAssessment Of Collateral Pathways In Acute Ischemic Cerebrovascular Stroke Using A Mansour Grading Scale; A New Scale, A Pilot Study
ISPUB.COM The Internet Journal of Interventional Medicine Volume 3 Number 1 Assessment Of Collateral Pathways In Acute Ischemic Cerebrovascular Stroke Using A Mansour Grading Scale; A New Scale, A Pilot
More informationCT/MRI 第 42 回日本脳卒中学会講演シンポジウム 総説 はじめに. MRI magnetic resonance imaging DWI diffusion-weighted. DWI/CBF malignant profile
第 42 回日本脳卒中学会講演シンポジウム 総説 CT/MRI 1 要旨 rt-pa MRI magnetic resonance imaging DWI diffusion-weighted image Tmax time-to-maximum DWI/PWI perfusion image mismatch CT computed tomography CBF cerebral blood flow
More informationEpidemiology. Epidemiology 6/1/2015. Cerebral Ischemia
Presenter Disclosure Information Paul Nyquist MD/MPH FCCM FAHA Updates on the Acute Care of Ischemic Stroke and Intracranial Hemorrhage Updates on the Acute Care of Ischemic Stroke Paul Nyquist MD/MPH,
More informationNew Stroke Interventions. Scott L. Zuckerman M.D. Vanderbilt Neurosurgery
New Stroke Interventions Scott L. Zuckerman M.D. Vanderbilt Neurosurgery Agenda Clot Retrieval Devices Merci Penumbra Stent Retrievers Solitaire Trevo New Technology Funnel ReCover MERCI Retriever (2004)
More informationAcute stroke update 2016 innovations in managing ischemic and hemorrhagic disease
Acute stroke update 2016 innovations in managing ischemic and hemorrhagic disease Christopher Koebbe, MD Endovascular Neurosurgeon Florida Spine Institute Director of Neurosciences Northside Hospital Overview
More informationAdvances in Acute stroke Management
Advances in Acute stroke Management Sandra Ripper-Brown, DNP Neuroscience Nurse Practitioner St. Mary s Medical Center WPB, FL Palm Beach County Nurse Practitioner Council Annual Conference APRNs: Agents
More informationEndovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) Policy Number: 2.01.54 Last Review: 11/2018 Origination: 4/2006 Next Review: 11/2019
More informationBasilar artery stenosis with bilateral cerebellar strokes on coumadin
Qaisar A. Shah, MD Patient Profile 68 years old female with a history of; Basilar artery stenosis with bilateral cerebellar strokes on coumadin Diabetes mellitus Hyperlipidemia Hypertension She developed
More informationACUTE ISCHEMIC STROKE
ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE HHS Stroke Annual Review March 7 and March 8, 2018 Objectives To review the stroke endovascular mechanical thrombectomy evidence
More informationInterventional Neuroradiology. & Stroke INR PROCEDURES INR PROCEDURES. Dr Steve Chryssidis. 25-Sep-17. Interventional Neuroradiology
Interventional Neuroradiology Interventional Neuroradiology & Stroke Dr Steve Chryssidis Interventional Neuroradiology (INR) is a subspecialty within Radiology INR -- broadly defined as treatment by endovascular
More informationHow to Manage LVO Stroke with Access Blocked by Cervical Carotid Occlusion
How to Manage LVO Stroke with Access Blocked by Cervical Carotid Occlusion November 1 st, 2017 Johanna T. Fifi, MD Director, Endovascular Ischemic Stroke Associate Professor of Neurology, Neurosurgery,
More informationDoor to Needle Time: Gold Standard of Stroke Treatment Fatima Milfred, MD. Virginia Mason Medical Center March 16, 2018
Door to Needle Time: Gold Standard of Stroke Treatment Fatima Milfred, MD Virginia Mason Medical Center March 16, 2018 2016 Virginia Mason Medical Center No disclosure 2016 Virginia Mason Medical Center
More informationRole of recombinant tissue plasminogen activator in the updated stroke approach
Role of recombinant tissue plasminogen activator in the updated stroke approach Joshua Z. Willey, MD, MS Assistant Professor of Neurology Division of Stroke, Columbia University October 2015 jzw2@columbia.edu
More informationOpening the Window for Stroke Intervention How Far Can We Go?
Opening the Window for Stroke Intervention How Far Can We Go? Raul G Nogueira, MD Associate Professor in Neurology, Neurosurgery, and Radiology Emory University Director, Neuroendovascular Service Grady
More informationStroke, Stroke, Stroke Where Do We Stop on the River? Comprehensive vs. Primary Stroke Centers
Stroke, Stroke, Stroke Where Do We Stop on the River? Comprehensive vs. Primary Stroke Centers Peter D. Panagos, MD, FAHA, FACEP Departments of Neurology and Emergency Medicine Washington University School
More informationSpontaneous Recanalization after Complete Occlusion of the Common Carotid Artery with Subsequent Embolic Ischemic Stroke
Original Contribution Spontaneous Recanalization after Complete Occlusion of the Common Carotid Artery with Subsequent Embolic Ischemic Stroke Abstract Introduction: Acute carotid artery occlusion carries
More information