Methods for endovascular treatment of cerebral vascular obstruction - own experience

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1 Methods for endovascular treatment of cerebral vascular obstruction - own experience Poster No.: C-2085 Congress: ECR 2013 Type: Scientific Exhibit Authors: M. Honkowicz, T. Kirmes, M. Koronski, M. Kysiak, M Bukanski, D. T. Knap, D. Sieron, J. Baron ; Gorlice/PL, Tychy/ PL, Nowy Sacz/PL, Stryszawa/PL, Kuznia Raciborska/PL, 6 Katowice/PL Keywords: Neuroradiology brain, Interventional vascular, Catheter arteriography, Thrombolysis, Recanalisation, Catheters, Obstruction / Occlusion, Embolism / Thrombosis, Ischemia / Infarction DOI: /ecr2013/C-2085 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

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3 Purpose The aim of study is to evaluate the effectiveness of cerebrovascular occlusion treatment with the use of invasive radiological techniques, targeted thrombolysis and mechanical thrombectomy. This study was conducted to demonstrate which of the endovascular aforementioned methods is more effective. It shows the impact of endovascular treatment of cerebral vascular obstructionaffects the clinical status of patients and which are the most frequently occluded arteries. Methods and Materials Materials: This retrospective study involved a group of 29 patients hospitalized in SP CSK im. prof. K. Gibi#skiego SUM in Katowice, who in were treated with targeted thrombolysis and mechanical thrombectomy. The average age of patients with obstruction of cerebral arteries was 56,72 years (with a range of years) (Table 1). Neurological examination (assessed using the National Institutes of Health Stroke Scale [NIHSS]) was performed before and after surgery and at discharge from the ward. Table 1 Qualifications protocol: In order to exclude patients with hemorrhagic stroke, procedures (CT, Angio-CT and/or DSA angiography) were performed at the start of diagnosis (Fig. 1, 2). Page 3 of 18

4 Fig. 1: Acute ischemic stroke, 67 years old woman, right-sided hemiparesis and hypoesthesia, central cranial nerve VII paralysis, head CT scan (3-4 hours after the onset of stroke), features of recent left-sided ischemia Fig. 2: Cerebral vascular obstruction, 67 years old woman, right-sided hemiparesis and hypoesthesia, central cranial nerve VII paralysis, head Angio-CT scan and spiral CT scan, MCA L occlusion If vascular changes were visualized, a procedure was applied according to the following scheme. A significant role in the treatment of stroke plays the start time of therapy aiming at streamlining vessels. However, the method thrombolysis i.v. can be applied only to the 4.5 hours after the first symptoms, which includes only 5% of patients. Thrombolysis i.a. (targeted) is an endovascular procedure of treating recent arterial thrombosis with the use of fibrinolytics: urokinase, recombinant tissue plasminogen activator (r-tpa) or streptokinase. It can be applied in selected patients with large stroke up to 6 hours after the onset of symptoms and/ or a contraindication to the use of thrombolysis i.v.. Page 4 of 18

5 For several years, the method of mechanical thrombectomy is used. This method consists in introduction of catheter into cerebral vessels that allow the mechanical removal of the embolism. They extend the therapeutic window for patients with large stroke up to 8 hours from onset of symptoms and/ or contraindicated or inefficient iv thrombolysis, which significantly increases the number of patients eligible for treating. This type of equipment includes a Penumbra set which uses a guidewire and a separator for mechanical thrombus fragmentation. A high rate of recanalization and a favorable clinical outcome in patients with occlusion of proximal parts of arteries can be achieved with a Solitaire stent. Clinical effects and the outcome of treatment depend mostly on the initial neurological status and the time in which treatment begins. Targeted thrombolysis: All procedures were performed with the initial puncture of the right femoral artery and introducing the catheter using the Seldinger method. A contrast agent was then administered to visualize the obstruction of the cerebral vessels. The diagnostic catheter was later replaced by a leading catheter and a coaxially introduced guidewire whose end was placed in the occluded vessel. Finally a 10 to 20 ml dose of r-tpa was given. During the procedure continuous rinsing, using a heparin solution in saline, of both the guiding catheter and the guidewire, was performed (Fig. 3). Fig. 3: Targeted thrombolysis, left MCA obstruction; (A) before treatment, (B) after treatment Mechanical thrombectomy: The procedure was performed with the initial puncture of the right femoral artery and introducing the catheter using the Seldinger method. The guidewire of the Penumbra system for mechanical thrombectomy was then coaxially introduced and aspiration of the thrombus was performed. The aspiration catheter was placed below the thrombus and the separator was introduced into the center of the thrombus. After connecting suction, Page 5 of 18

6 the seperator broke up the thrombus and the fragments were aspired. When using the Solitaire stent, it was depressurized above the thrombus without complete release. The thrombus was then pulled through the leading catheter. During the procedure rinsing with heparin solution in saline, of both the guiding catheter and the guidewire, was performed (Fig. 4). Fig. 4: Mechanical thrombectomy - Solitaire FR, right MCA occlusion; (A) before treatment, (B) after treatment Classification TICI: The success of recanalization and reperfusion have been evaluated using TICI scale with assigning five classification degrees (Table 2). Page 6 of 18

7 Table 2 Control after intervention: After the procedure were performed CT and DSA angiography in order to assess patency and exclude intracranial hemorrhage (Fig. 5). Fig. 5: Control after procedure; achieved flow through BA References: Student Scientific Society of Interventional Radiology, Medical University Images for this section: Table 1 Page 7 of 18

8 Fig. 1: Acute ischemic stroke, 67 years old woman, right-sided hemiparesis and hypoesthesia, central cranial nerve VII paralysis, head CT scan (3-4 hours after the onset of stroke), features of recent left-sided ischemia Fig. 2: Cerebral vascular obstruction, 67 years old woman, right-sided hemiparesis and hypoesthesia, central cranial nerve VII paralysis, head Angio-CT scan and spiral CT scan, MCA L occlusion Page 8 of 18

9 Table 2 Fig. 4: Mechanical thrombectomy - Solitaire FR, right MCA occlusion; (A) before treatment, (B) after treatment Fig. 3: Targeted thrombolysis, left MCA obstruction; (A) before treatment, (B) after treatment Page 9 of 18

10 Results In the period from 2005 to 2012, 29 cases with cerebrovascular occlusion were treated. 38 endovascular procedures were performed: 24 targeted thrombolysis and 14 mechanical thrombectomy. Mechanical thrombectomy was performed using 7 Penumbra sets, 5 Solitaire FR sets and twice using the microcatheter and microguidewire. The combination therapy (targeted thrombolysis and mechanical thrombectomy) was used 4 times (Table 3). The 7 times during thrombolysis was used ReoPro (Abciximab), 16 times the rt-pa. In 7 cases of the vascular spasm papaverine was applied. Table 3 Obstruction occurred most frequently in the middle cerebral artery (41,67%), basilar artery (16,67%), vertebral artery (11,11%) and internal carotid artery (11,11%). (Table 4). Page 10 of 18

11 Table 4 We evaluated 29 patients with cerebrovascular obstruction who underwent invasive treatment. Neurological status of patients before treatment, assessed using the NIHSS scale, ranged from 0 to 23 (mean 10.31, SD ± 5.27). The status of patients after treatment, according to the NIHSS scale, ranged from 0 to 15 with an average of 6.86 (SD ± 4.57). However, on the day of discharge from the hospital, the status of patients, was in the range of 0 to 16 with an average of 5.93 (SD ± 4.85) (Table 5.2). The mean time from symptom onset to recanalization was 390 minutes (with a range of minutes). The mean duration time of the procedure was 98 minutes (with a range of minutes) and 53 minutes for efficient procedures. Page 11 of 18

12 86.21% of all patients had improved neurological status (assessed using the NIHSS scale) after treatment and the status level was maintained increased to 93,10% the day of discharge. 76,32% of all procedures performed resulted in successful recanalization (TICI 2a, TICI 2b/3) (Table 5.1), thus succeeding to obtain blood flow through brain vessels in 79.31% of patients. Among these, clinical improvement in NIHSS was 82.61%. (Table 5.3). Table 5 Mechanical thrombectomy treatment performed using the Penumbra system ended in the clearing of 42.86% of obstructed vessels, the use of the Solitaire FR set was successful in 100%. The overall efficiency of mechanical thrombectomy (Penumbra + Solitaire FR + microcatheter and microguidewire) was 71.43%. The efficiency of targeted thrombolysis was 79.17% (Table 6). Page 12 of 18

13 Table 6 Images for this section: Page 13 of 18

14 Table 3 Table 4 Page 14 of 18

15 Table 5 Page 15 of 18

16 Table 6 Page 16 of 18

17 Conclusion The research performed has shown that endovascular techniques are effective and safe in the treatment of cerebral vascular obstruction. Targeted thrombolysis is more effective than mechanical thrombectomy. Patients who were treated endovasculary improved significantly. The middle cerebral artery was the most common site of obstruction. References 1. Jan Baron i Joanna Pilch-Kowalczyk, Wprowadzenie do diagnostyki obrazowej, Wydanie: II, ISBN: Castro-Afonso LH, Abud TG, Pontes-Neto OM, Monsignore LM, Nakiri GS, CougoPinto PT, Oliveira Ld, Santos DD, Dias FA, Fábio SC, Coletto FA, Abud DG, Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population, Clinics (Sao Paulo) Dec;67(12): [PubMed] 3. Bae GS, Kwon HJ, Kang CW, Choi SW, Kim SH, Koh HS, Mechanical thrombectomy using a solitaire stent in acute ischemic stroke; initial experience in 40 patients, J Cerebrovasc Endovasc Neurosurg Sep;14(3): [PubMed] 4. Piotr Sobolewski, Review of invasive endovascular methods of treatment in the patients with acute ischemic stroke, Udar Mózgu 2011, tom 13, nr 1-2, 5-11 Copyright 2011 Via Medica ISSN Adam Kobayashi, Endovascular approaches for acute ischaemic stroke: the current evidence and organizational issues, Postep Kardiol Inter 2012; 8, 3 (29): Penumbra Pivotal Stroke Trial Investigators. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke Aug;40(8): [PubMed] 7. Castano C, Dorado L, Guerrero C, Millan M, Gomis M, Perez de la Ossa N, et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke Aug;41(8): [Pubmed] Page 17 of 18

18 8. S. Stampfla, M. Hartmanna, P.A. Ringlebb, S. Haehnela, M. Bendszusa and S. Rohdea, Stent Placement for Flow Restoration in Acute Ischemic Stroke: A Single-Center Experience with the Solitaire Stent System, AJNR : M.A. Almekhlafi, B.K. Menon, E.A. Freiheit, A.M. Demchuk, M. Goyala, A MetaAnalysis of Observational Intra-Arterial Stroke Therapy Studies Using the Merci Device, Penumbra System, and Retrievable Stents, AJNR : Personal Information Daniel Knap, PhD, Medical University of Silesia, Katowice, Poland; Maciej Honkowicz, student, Medical University of Silesia, Katowice, Poland; m.honkowicz@gmail.com Tomasz Kirmes, student, tomaszkirmes@gmail.com Medical University of Silesia, Katowice, Poland; Marcin Koro#ski, student, Medical University of Silesia, Katowice, Poland; Marzena Kysiak, student, Medical University of Silesia, Katowice, Poland; Mateusz Buka#ski, student, Medical University of Silesia, Katowice, Poland; Jan Baron, PhD, Medical University of Silesia, Katowice, Poland; Page 18 of 18