Latest Advances in the Neurointerventional Treatment of Ischemic Stroke P A C I F I C N E U R O. O R G
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1 Latest Advances in the Neurointerventional Treatment of Ischemic Stroke
2 Neurointerventional Management of Ischemic Stroke 1. Thrombectomy for acute ischemic stroke 2. Carotid artery stenting 3. Management of vertebrobasilar disease 4. The latest in management of intracranial atherosclerosis disease (ICAD)
3 Thrombectomy Revolution in Stroke Care NNT to reduce disability is One of the most effective therapies in medicine Only available at highly specialized centers 3 4
4 We have 8 positive trials of thrombectomy in the <6 hour window % TPA Enrolled up to: % 2 Int vs. cont Note MR CLEAN 87 vs 90% 6hrs 33 vs 19% Did not use ASPECTS for enrollment EXTEND-IA 100% tissue not time 71 vs 40% ESCAPE 73 vs 79% Up to 12 hrs (only 16% >6hr) 51 vs 29% SWIFT-PRIME 100% Up to 6 hrs 60 vs 35% REVASCAT 70 vs 80% 8hrs 44 vs 28% Waiting for TPA to fail THRACE 100% IR started <5 finished <6 54 vs 42% THERAPY 100% Enrolled <4.5 hrs 38 vs 30% Used Penumbra Adapt rather than stentriever PISTE 100% 6 hrs Terminated early
5 The DAWN Trial was just presented at European Stroke Organisation Conference in May 2017 Approach applies advanced perfusion imaging to select patients who could benefit from thombectomy in the late 6-24 hour window Now represents the most positive thrombectomy trial to date with a NNT of only 2 to reduce disability
6 Case 1 - St John s wake up stroke 74 year old high functioning CPA who woke up with symptoms concerning for stroke. He had rightward gaze deviation, left face/arm/leg weakness, sensory loss, hemineglect, and visual field cut. NIHSS was 20
7 Case 1 - St John s wake up stroke CT Perfusion showed small core infarct (dead brain) and large penumbra (at risk brain)
8 Case 1 - St John s wake up stroke CT Perfusion showed small core infarct (dead brain) and large penumbra (at risk brain)
9 Case 1 - St John s wake up stroke CT Perfusion showed small core infarct (dead brain) and large penumbra (at risk brain)
10 Case 1 - St John s wake up stroke CT Perfusion showed small core infarct (dead brain) and large penumbra (at risk brain)
11 Case 1 - St John s wake up stroke CT Perfusion showed small core infarct (dead brain) and large penumbra (at risk brain)
12 Tandem Lesions
13 Tandem Lesions Right Internal Carotid Right Middle Cerebral
14 Tandem Lesions Here our microwire and microcatheter are going up the left internal carotid artery, over the Anterior Communicating artery, and down the right occluded cervical carotid artery
15 Tandem Lesions A. B. A. Our wire from above shows us where to go to open the right carotid B. After stenting the carotid we have an easy path to treat the MCA occlusion
16 Tandem Lesions A. B. A. Injection shows occlusion at the carotid terminus B. After thrombectomy, the MCA fully reperfused and filling anterograde
17 MRI shows much smaller area of stroke than the at risk territory Patient recovered to NIHSS of 3 immediately after the case
18 Discharged to Acute Rehab after just 4 days and now back to his pre-stroke baseline.
19 Carotid Artery Stenting With modern techniques in carotid artery stenting, the latest trials shows stenting and CEA to be equal and very effective therapies for treating carotid artery stenosis - Brott et al, NEJM Rosenfield K et al, NEJM Brott et al, NEJM 2016
20 Carotid Artery Stenting The CREST Trial (Brott et al, NEJM 2010)
21 Carotid Artery Stenting CREST 10 year Results Stenting Endarterectomy Stenting Endarterectomy Brott et al, NEJM 2016
22 Carotid Artery Stenting ACT-1 trial for asymptomatic carotid artery stenosis 18 times fewer strokes than the medical arm of NASCET Rosenfield K et al, NEJM 2016
23 Vertebrobasilar Stenosis The VERITAS Trial shows us that stroke risk from posterior circulation atheroscloti disease is largely related to flow status Amin-Hanjani et al JAMA Neurol. 2016
24 Vertebrobasilar Stenosis VERITAS enables us to risk stratify patients and prescribe therapy that is proportional to their ongoing stroke risk Amin-Hanjani et al JAMA Neurol. 2016
25 Vertebrobasilar Stenosis VERITAS enables us to risk stratify patients and prescribe therapy that is proportional to their ongoing stroke risk Consider stenting or bypass Medical management Amin-Hanjani et al JAMA Neurol. 2016
26 The latest in management of intracranial atherosclerosis disease (ICAD)
27 The latest in management of intracranial atherosclerosis disease (ICAD)
28 The latest in management of intracranial atherosclerosis disease (ICAD) - Patient selection is key - Interim data from first 100 patients very encouraging - much lower complication rate (2.9%) than Sampriss (14.7)
29 Multidisciplinary team approach to treatment and advancing understanding cerebrovascular disease
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