BGS Spring Conference 2015

Transcription

1 Neuroradiology in hyperacute stroke: what is the UK position? Dr Shelley Renowden Bristol

2 NICE HIS July, 2013 The current evidence on mechanical clot retrieval for treating acute ischaemic stroke shows that efficacy is unproven.suitability for thrombolysis can be guided by criteria used in the PISTE trial. 1.1 Patients with acute ischaemic stroke for whom thrombolysis is unsuitable/failed;.only performed with special arrangements for clinical governance, consent, audit, research 1.2 Patients with acute ischaemic stroke for whom thrombolysis is suitable:..used only in the context of research, which should in be RCTs comparing mechanical clot retrieval or the current methods of management and should report details of patient selection, timing of the intervention after onset of symptoms, the devices and techniques used, complications and functional outcomes NICE encourages clinicians to enter patients into RTs such as PISTE we have been doing thrombectomy in selected patients.

3 ischaemic stroke patient age co-morbidites (age, diabetes) NIHSS site, extent of occlusion collateral circulation extent of recanalisation time from ictus to recanalisation SICH leukoariosis

4 NIHSS NIHSS > % chance of good outcome at 1yr cf 60-70% in those with NIHSS <10 see Balami et al, Brain, 2013, 136, )

5 IV TPA / NIHSS: STOPSTROKE good poor outcome NIHSS 0-5 n=352 no iv tpa 81% 19% iv tpa 70% 30% p=0.31 NIHSS 6-10 n= 109 no iv tpa 52% 48% iv tpa 74% 26% p=0.038 NIHSS n=79 no IV tpa 35% 65% iv tpa 50% 50% p=0.15 NIHSS >=16 n= 109 no iv tpa 12% 88% iv tpa 27.5% 72.5% p=0.034 Gonzalez et al, Stroke, 2013, 44,

6 NIHSS and LVO? median NIHSS in M1 occlusion is 14 NIHSS % PPV LVO 48% sensitivity 55% of pts with NIHSS 10 - had LVO LVO in 90% NIHSS 16+ LVO in 100% NIHSS 27+ Maas et al, Stroke, 2009, 40,

7 Effect of IV TPA and occlusion site prox MCA distal MCA ICA/MCA TICA BA n NIHSS 18 (6-32) 13 (3-29) 19(6-29) 20(11-28) 27 TIMI 3 30% 44% 27% 6% 35% <2hr p=0.007 early 16% 33% 24% 0% 25% Improvement p= day 25% 52% 21% 18% 25% mrs<=1 p<0.001 mortal 24% 17% 14% 45% 75% 90 day p= Saqqur et al Stroke 2009 (Clotbust)

8 location of thrombus, outcome, anterior circulation stroke IVT, within 3 hours impact of thrombus location on CTP, % salvaged brain ICA M1p M1d M2-3 age` NIHSS onset to TPA ASPECTS infarct vol ml (mean) mrs % 82% 86% 90 days Sillanpaa et al, AJNR, 2013

9 final infarct volumes: EVT cf IVT in LVO 203 pts; LVO; mean age 66; median NIHSS 19; median infarct volume smaller for EVT (42cm3) cf IVT (109cm3) no Rx group (110cm3) EVT IV TICA occ M1 MCA M NIHSS Rangaraju et al, JAMA Neurology, 2013, 70,

10 clot length occlusion location is the strongest predictor of clot length (Kamaliam et al, Stroke 2013, 44, ) clot length 8+mm in 94% TICA, 73% M1 and 22% M2 occlusions IVT has no potential to recanalise occluded vessels if thrombus length > 8mm (Riedel et al, Stroke 2011, 42, )

11 7+ - predicts independent outcome

12 57F, AF, 3.5 hours after ictus left facial weakness, dense right hemiparesis (0/5) extensor R plantar left VFD severe expressive dysphasia NIHSS 20 ASPECTS 7

13

14

15 CTA normal parenchyma 71 F, NIHSS sec CT Brain

16 Recanalise Recanalisation using combined intravenous altepase and neurointerventional algorithm for acute ischaemic stroke n 90/7 favourable early neuro improvement outcome TIMI % 14% TIMI % 44% TIMI % 73% p < Mazighi et al, Stroke, 2009

17 IV TPA- recanalisation rates CTA database Calgary Stroke programme 216 pts- IV TPA; 103 went on to IA TPA M1-32.3%(43.1%); TICA 4% (39.1%); M2 31%(61.5%); BA 4% (52%) 60.5% who recanalised had good outcomes cf 24.3% who did notstrongest predictor of good outcome early recanalisation is associated with a better outcome than late Bhatia et al, Stroke, 2010, 41,

18 time from ictus to recanalisation IMS III - every 30 min delay in reperfusion is associated with 10% relative reduction in probability of a good outcome MRCLEAN OR for good outcome decreasing from 3.0 at 3.5 hours post ictus to reperfusion to 1.5 at 6 hours for each hour delay from ictus to TICI 2b/3 odds of good clinical outcome decreased by 38% - Menon et al, Stroke 2014 for every minute of arterial occlusion 1.9 million neurons and 14 billion synapses are lost

19 Recanalise n 90/7 favourable early neuro improvement outcome >260 mins 16 37% 37% mins 15 67% 73% ( 0.07) <210 mins 15 93% 93% (0.01) Mazighi et al, Stroke, 2009

20 stent retriever

21 71F, NIHSS ictus 9.30am

22 SPEED SWIFT,TREVO - 2 RCTS USA median time to Rx 4.6 and 4.7 hours mrs % 40% STAR, TREVO EU median time to Rx 3.2 and 3.4 hours mrs % 55%

23 STAR prospective, 14 centres, 202 consecutive pts mean age 72, mean NIHSS 17, anterior circulation occlusion, Solitaire TICA 18%; M1 67%; M2 14% 59% IV TPA treated within 8 hours; median time from ictus to groin puncture 238 mins procedure time 29+/-27 mins balloon guide catheter, flow reversal mandatory TICI 2b/3 79% mrs % mortality 7% SICH 1.5% good collaterals correlate with good outcome p=0.034 Perreira et al, Stroke 2013, 44,

24 74M ictus NIHSS 21

25

26 15.34

27

28 ADAPT - a direct aspiration first pass technique 37 consecutive pts (39-90 years old) (4 month study period) mean NIHSS 16.3 (5-30) M1 17; TICA 7; basilar 7; M2 5; M3 1; ADAPT alone successful in 75% flexible large bore catheter to thrombus. Aspiration with 20 or 60 ml syringe or Penumbra aspiration pump. Engage catheter in thrombus, then slowly withdraw with suction 9 required addition of stent retriever mean time from groin puncture to TICI 2b/3 28mins TICI 2b/3 in 100% TICI 3 in 65% 1 procedural complication (asymptomatic small SAH) 2 SICH mean NIHSS 4.2 at discharge (24pts (65%) 5 or below) 5 deaths Turk et al, JNIS 2014,

29 S BG rin g Sp 65M, NIHSS 22 on f C ce er en 15 20

30 Souza et al AJNR, 2012, 33, % bad outcome

31 105 consecutive pts, IV TPA within 3 hours median NIHSS 13 28% 18% 20% 29% 2% Saarinen et al AJNR, 2014

32 distal clot distal M1, M2, M3 good collaterals Souza 2-4

33 72M, NIHSS ictus 10.30am normal parenchyma

34 rin g C on f er en ce IV TPA running S Sp BG TICI pm

35 NIHSS 1

36 67M ;NIHSS 23 ictus 7am 8.37am 8.37am

37 80 sec head

38 9.30 am 10.28am

39

40 MRCLEAN NEJM, 2015, centres, Netherlands, Dec March pts, proximal anterior circulation occlusion (CTA/MRA)IAT cf usual Rx - 267pts- IVTPA; 233 EVT within 6 hours NIHSS 2 -: average 17, 18; ASPECTS 9 (median) in each group. 233 IAT (38% GA), acute carotid stenting 13% Mean age 65yrs: range yrs 445 pts IV TPA before randomization.time ictus to random mins Stentretrievers in 97% Independence in 32.6% cf 19.1% ; infarct vol at 7 days 49 cf 80ml No difference in mortality (7days: 12% each gp; 19% at 30) or SICH (18%: 17%) IAT usual ICA/M1 25% 28% M1 66% 62% M2 8% 8% A1/A2 32% 26% Time ictus to groin puncture 260 minutes (median) TICI 2b/3 in 59% FU CTA /MRA 24 hours - no occlusion in 75% cf 33%

41 EXTEND IA NEJM 2015 IV TPA within 4.5 hours cf EVT stent retriever 70 pts enrolled; 35 each arm; stopped prematurely ICA or MCA occlusion CTP ischaemic core <70 ml. EVT within 6 hours Ischaemic core at presentation / ml Perfusion volume at presentation 116 +/- 48ml IV TPA Median NIHSS /- 18.5ml 103 +/- 39ml IV +EVT ICA 31% 31% M1 51% 57% M2 17% 11% Median time ictus to groin puncture Median time ictus to TICI 2b/3 TICI 2b/3 in 86% 210 mins 248 mins 90 day mrs % 71% p=0.01 No significant difference in mortality and SICH; 12% GA. NNT 3

42 SWIFT PRIME, NEJM 2015 Stopped prematurely after 196 pts, 39 centres All had IV TPA within 4.5 hours, NIHSS 8-29 (11O 17+) YEARS OLD LVO anterior circulation ASPECTS > 6; CT EIC < 1/3 MCA territory EVT within 6 hours; 88% complete reperfusion mrs 0-2 at 90 days 60.2% EVT cf 35.5% IVT p<0.001 NNT 4 SICH 0% cf 3% (IV) Mortality at 90 days 9.2% cf 12.4% (IV) Ictus to arterial puncture was min (IQR) Ictus to first deployment of Solitaire min (IQR)

43 REVASCAT NEJM pts within 8 hours, 4 centres in Spain, halted early because of other trials years old, NIHSS 6+ (IQR ; median 17) ASPECTS < 7 excluded Later years ASPECTS 8+ IV TPA cf IV TPA and Solitaire, anterior circulation LVO 6.7% GA Wait 30 mins for IVTPA mrs 0-2 at 90 days 44% cf 28% OR day mortality 18.4% cf 15.5% SICH 2% each arm Median time from ictus to groin puncture 269mins ( ) Median time from ictus to revascularisation 355 mins ( )

44 ESCAPE NEJM 2015 LVO anterior circulation, within 12 hours, ASPECTS 6-10; poor collaterals excluded Standard care cf thrombectomy; enrolment up to 12 hours Stopped early 49 (15.5%) randomized after 6 hours 22 centres, 316 pts; 238 received IV TPA (120 in EVT group) Median time from CT to reperfusion was 84 mins and from ictus to reperfusion, 241 mins EVT IVT Median NIHSS ASPECTS 9 (8-10) 9(8-10) ICA + M1 27.6% 26.5% M1 or all M2 68.1% 71.4% M2 single 3.7% 2.0% 90 day mrs % 29.3% p<0.001 Mortality 10.4% 19% SICH 3.6% 2.7% GA 9%

45 MRCLEAN OR for good outcome decreasing from 3.0 at 3.5 hours ictus to reperfusion to 1.5 at 6 hours treatment effect not statistically significant if reperfusion after 6 hours 19 mins ESCAPE- 15.5% pts were treated successfully after 6 hours collaterals extending time window based on imaging

46 MRCLEAN 16% were 80+ years old significant benefit from EVT- similar to entire EV cohort : OR 3.24 ESCAPE, SWIFT PRIME also showed benefit for those 80+ (oldest in ESCAPE was 93!) MRCLEAN EVT beneficial with ASPECTS 5+ not 4 and below

47 ESO-Karolinska Stroke Update with ESMINT, ESNR mechanical thrombectomy with IV TPA within 4.5 hours, LVO, anterior circulation up to 6 hours after ictus (level of evidence A/1a) decision jointly by multidisciplinary team including stroke physician and INR, experienced centre thrombectomy by trained experienced INR large infarcts excluded

48 NICE HIS July, 2013 The current evidence on mechanical clot retrieval for treating acute ischaemic stroke shows that efficacy is unproven.suitability for thrombolysis can be guided by criteria used in the PISTE trial. 1.1 Patients with acute ischaemic stroke for whom thrombolysis is unsuitable/failed;.only performed with special arrangements for clinical governance, consent, audit, research 1.2 Patients with acute ischaemic stroke for whom thrombolysis is suitable:..used only in the context of research, which should in be RCTs comparing mechanical clot retrieval or the current methods of management and should report details of patient selection, timing of the intervention after onset of symptoms, the devices and techniques used, complications and functional outcomes NICE encourages clinicians to enter patients into RTs such as PISTE

49 ?

50

51 PISTE 18 years+, eligible IV TPA within 4.5 hours LVO, NIHSS 6+ EVT must be started within 90 mins of the IV TPA; groin puncture no more than 5.5 hours post ictus; angio within 6 hours 90 day mrs 0-2 mrs 0-1, mortality, eni 8+ NIHSS or NIHSS 0,1 at 72 hours, angio patency, immediate revascularisation rate, home time, sich etc