Endovascular Therapy: Beyond the Guidelines

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1 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

2

3 Challenges in patient selection - Delays in presentation - Fast rate of tissue injury - No clear EKG - Concern for reperfusion injury

4 What is the total pool of guideline patients? Age >= 18 mrs 0-1 NIHSS >6 Small infarct M1/ICA occlusion Presenting within 6 hours Meet guidelines for treatment

5 What is the total pool of guideline patients? Age >= 18 mrs 0-1 NIHSS >6 Small infarct M1/ICA occlusion Presenting within 6 hours 6% Meet guidelines for treatment 300,000 18,000

6 Patient selection PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Patient specific criteria: - Adults (age >= 18) - Functionally independent (pre-stroke mrs 0-1)

7 Prognosis versus treatment effect - advanced age is associated with worse outcomes after ischemic stroke however the treatment effect is higher - advanced age is not a contra-indication but baseline disability or cognitive issues may limit benefit

8 Patient selection: stroke size PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Patient specific criteria: Small established infarct (ASPECT of >= 6)

9 Patient selection: stroke size PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED ASPECT 7 ASPECT 4

10 Benefit in larger stroke? Only 9% of patients treated had large core (ASPECT 0-5) but no clear evidence of harm and trend towards benefit

11 Mortality with infarct size Infarct volume of 145 or larger: high death rate without craniectomy On the contrary, if 145 cc or less: none died without craniectomy

12 Stroke size and cost: each additional 1cc of infarcted brain tissue increased hospitalization cost by $ Streib et al (submitted)

13 Patient selection PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Patient specific criteria: Received IV tpa

14 Patient selection PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Patient specific criteria: - Limited data in pediatrics - No age cutoff - Benefit in patients who are not tpa eligible - Persistent benefit despite large infarct (particularly in younger patients with potential for malignant edema)

15 Site of occlusion PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Basilar occlusion: 20%

16 What about basilar occlusions? 50% good outcomes

17 Distal occlusions PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED 50% good outcomes

18 What about distal occlusions? 62.8 % vs 35.4% good outcomes

19 Process of care PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Treatment can be initiated (groin puncture) within 6 hours of symptoms onset

20 Improve Process

21 What about beyond 6 hrs? 1. No approved medical therapies 2. Account for 14-28% of strokes 3. May have salvageable brain tissue

22 Fast progressor Int J Stroke Jul; 10(5):

23 Slow progressor Int J Stroke Jul; 10(5):

24 Fast versus slow progressors

25 Pre-DAWN data

26 DAWN trial patients (feasability); 500 patients (pivotal); 50 sites hours 3. NIHSS > 9 4. < 1/3 MCA territory involved, as evidenced by CT or MRI Clinical Imaging Mismatch (CIM) defined as one of the following on RAPID MR-DWI or CTP-rCBF maps: 0-20 cc core infarct & NIHSS >= 10 (& >= 80 yrs old) 0-30 cc core infarct & NIHSS >= 10 (& < 80 yrs old) 31 to 50 cc core infarct & NIHSS 20 (& < 80 yrs old) 5. ICA/M1 occlusion 6. Medical therapy versus IAT (upto 6 passes of Trevo)

27 DAWN trial

28 Expanding the indication? Age >= 18 mrs 0-1 NIHSS >6 Small infarct M1/ICA occlusion Presenting within 6 hours Meet guidelines for treatment

29 Speed and quality of recanalization PATIENT SELECTION PRESENCE OF OCCLUSION PROCESS OF CARE PROCEDURAL TIME PERFUSION ACHIEVED Currently no specific guidelines for: door to access times and rates of high quality of perfusion

30 Summary - Current guidelines given class IA recommendation for a subset of patients - A larger subset of patients likely benefit from endovascular therapy with no absolute contra-indications based on: - Age - Site of occlusion - IV tpa ineligible - Time of symptoms onset

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