Overview. Introduction. New Interventions for Acute Stroke. New Approaches to hemorrhagic Strokes

Transcription

1 Overview New Interventions for Acute Stroke Paula Eboli, MD Department of Neurosurgery Rockwood Clinic, Deaconess Hospital Introduction New Approaches to hemorrhagic Strokes New Approaches to Ischemic Strokes LVO strokes Case examples Conclusion Questions Spokane County EMS 2 Introduction New Approaches to hemorrhagic Strokes Paula Eboli, MD Department of Neurosurgery Rockwood Clinic, Deaconess Hospital Non traumatic ICH is a major public health problem Is the most common type of hemorrhagic stroke 4 times more common than subarachnoid hemorrhage 15% of all strokes Annual incidence of per population Accounting for 2 million (10 15%)of about 15 million strokes worldwide each year Hospital admissions for intracerebral hemorrhage increased by 18% in the past 10 years Probably because of increases in the number of elderly people Lack of adequate blood-pressure control Increasing use of anticoagulants, thrombolytics, and antiplatelet agents Intracerebral hemorrhage commonly affects Cerebral lobes Basal ganglia Thalamus Brainstem (predominantly the pons) Cerebellum Mortality rates are as high as 40% to 50% When associated with IVH mortality rates are between 50% and 80% Spokane County EMS

2 Pathophysiology Hemostasis is initiated by local activation of hemostatic pathways and mechanical tamponade About 73% of patients assessed within 3 h of symptom onset have some degree of hematoma enlargement Most hematoma enlargement occurs within 3 h Although enlargement can occur up to 12 h after onset Up to 35% have clinically prominent enlargement Clinical Presentation Symptoms are related to the size and location of hematoma Classic presentations Rapid-onset focal neurological deficits Decreased consciousness Signs of brainstem dysfunction Neurological deterioration is common before and during hospital admission Hematoma enlargement Worsening of edema Descriptors of disease severity are predictive of early death Age Initial score on the Glasgow coma scale (GCS) Hematoma volume Ventricular blood volume Hematoma enlargement A. Initial hematoma B. Expansion 2.5h C. Progression 3.5h D. Stabilization 4.5h 6 CT scanning is the first-line diagnostic approach MRI with gradient echo can detect hyperacute ICH CTA is needed to diagnose secondary causes, aneurysms, arteriovenous malformations, dural venous thromboses, and vasculitis If suspicious CTA, diagnostic cerebral angiogram is recommended MRI can also identify secondary causes such as cavernous malformations, although their sensitivity in the acute phase is not well established Diagnosis Differential diagnosis 24 yo.

3 Management ICH is a medical emergency Rapid diagnosis and attentive management is crucial More than 20% of patients will experience a decrease in the GCS of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the ED Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival A single-center study found that prolonged patient stays in the ED lead to worse outcomes Rapid admission to a stroke unit or neuroscience intensive care unit Early management while the patient is awaiting this bed Urgent treatment of time-sensitive issues including BP lowering and reversal of coagulopathy should be initiated in the ED New MIS Technologies for ICH Evacuation Paula Eboli, MD Department of Neurosurgery Rockwood Clinic, Deaconess Hospital Spokane County EMS Apollo System Received FDA in 2014 Cranial access burr hole or mini craniotomy Evacuation is performed under continuous endoscopic visualization under stereotactic guidance low-profile wand for aspiration and vibrational element to break down the hemorrhagic products It s placed through a small BrainPath craniotomy. The sheath is stereotactically placed The Myriad Handpiece into the distal aspect of the clot along the longest axis of the hematoma. The obturator is removed, and the hemorrhage can be resected either with Standard suction Myriad handpiece Visualization -Microscope or exoscope The BrainPath sheath 11 12

4 Case 1 Left parietal craniotomy for evacuation of ICH 81-year-old male PMH. Hypertension Was found down at a law office He was nonverbal and aphasic upon arrival SBP was 185/106 PE PERL Unable to assess facial symmetry Doesn't follow commands RUE Flexion LUE Spontaneous antigravity RLE Triple flexion LLE Withdrawal 13 Mental status did not improve much. DC to SNF on a puree diet yo male Chronic alcohol abuse Was just recently admitted for alcohol withdrawal and was discharged same day Found down Lethargic and not speaking, intubated for airway protection and transferred for higher level of care PE Intubated, not following commands Pupils 3mm bilaterally reactive RUE flex RLE triple flex LUE and LLE moving spontaneously antigravity Case 2 Admission CT/CTA 15 16

5 Left temporoparietal craniotomy for ICH evacuation Stereotactic volumetric guidance with IGS system Interventions for Acute Ischemic Stroke Paula Eboli, MD Department of Neurosurgery Rockwood Clinic, Deaconess Hospital PE: Opens eyes to voice, PERRLA, LUE flexing,lle withdraws,rue minimal movement to stim RLE triple 17flexion Spokane County EMS Introduction IV-tPA first available FDA approved treatment for AIS Neurothrombectomy device - defined by the FDA as a device intended to retrieve or destroy blood clots in the cerebral neurovasculature by mechanical, laser, ultrasound technologies, or combination of technologies Merci retriever was the first endovascular device to receive FDA clearance Penumbra System was cleared by the FDA the FDA approved two new devices Trevo Pro and Solitaire stent retrievers after they were shown to have superior rates of recanalization when compared to the Merci 19

6 Approach to a LVO stroke Number Needed to Treat (NNT) to see benefit 40 pts. Thrombolytic for STEMI within 6 hours to prevent death 10 pts. Endarterectomy for symptomatic carotid artery stenosis to prevent stroke 3 pts. Brain Artery Embolectomy to see better outcome at 90 days 4 pts. Brain Artery Embolectomy To achieve independence at 90 days Class I; Level of Evidence A Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria Prestroke mrs score 0 to 1 Acute ischemic stroke receiving intravenous r-tpa within 4.5 hours of onset according to guidelines from professional medical societies Causative occlusion of the internal carotid artery or proximal MCA (M1) Age 18 years NIHSS score of 6 ASPECTS of 6 treatment can be initiated (groin puncture) within 6 hours of symptom onset Class IIa; Level of Evidence C Patients who have contraindications to intravenous r-tpa, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable Patients who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries Patients <18 years of age with acute ischemic stroke Patients who have prestroke mrs score of >1, ASPECTS <6, or NIHSS score <6 and causative occlusion of the internal carotid artery or proximal MCA (M1) 22 Endovascular mechanical thrombectomy devices The Penumbra system (Penumbra Inc., CA, USA) presents another approach to mechanical thrombectomy This system places a reperfusion catheter proximal to the clot Penumbra system ADAPT technique Utilizes a proximal approach to the target occlusion from which a large aspiration catheter suctions out thrombus with minimal distal emboli Spokane County EMS 24

7 Superior right M2 occlusion 56 year old man with a history of heart failure, A fib, Pacemaker, renal insufficiency Ejection fraction 12% Creatinine 2.4 ASPECTS score 7 Acute onset left hemiplegia, dysarthria, neglect Admission NIHSS 12 Received IV tpa 2 hours post onset of symptoms ACE clot engagement

8 Baseline Post Thrombectomy Judging TICI based on AP alone is inadequate. The distinction inction between TICI 3 and TICI 2b is better made on lateral al angio NIHSS - 12 NIHSS - 0 Groin Admission CT 24 hour CT

9 Trevo device (Stryker) First device to surface in this group in Europe in 2010 August 2012, the FDA granted clearance for use in patients with acute ischemic stroke Stent retrievers The Solitaire (Covidien/Medtronic) In March 2012, US FDA granted approval Trevo vs. Solitaire Visible Under Fluoroscopy Size of 4mm and 6mm Size 3,4, and 6mm diameter diameters 34 Case #1 81-year-old man Presented with acute onset of aphasia and right-sided hemiplegia Received intravenous tpa NIH stroke scale score was 23 CTA. L M2 occlusion 35 36

10 CT Perfusion Cerebral angiogram x15 Solitaire thrombectomy device (1pass) Full revascularization TICI

11 Physical Exam at discharge Awake, alert. MS intact to conversation. CN II-XII intact. Motor full bilateral UE, full strength bil LE symmetrically. Sensation intact throughout 41 Blood flow / Blood volume mismatch

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13 CT 6 hours post Strict BP Control with CT showing staining BP < 140 Post-procedural management If TICI 3, maintain normal blood pressure range SBP Avoid hypertension to minimize reperfusion hemorrhage If TICI 2a or 2b, may still be dependent on collaterals, so keep blood pressure and blood volume up, SBP Conclusions Mechanical al Thrombectomy lessons Higher TICI 3 rate Faster technique Better outcomes Less embolic sequelae With Level 1A evidence that embolectomy has better outcomes this is now the standard of care for Large Vessel Occlusion. Patient transport to centers that can provide this procedure should be expedited

14 THANK YOU Special thanks to Sheila Crow Stitchin Dreams Embroidery For providing our Secret Question prize Spokane County EMS Questions? Contact: Samantha Roberts Fax: Updates Please EMS presentation, all certificates will be printed by participants or their agency. The certificate template will be available through the health training website at the same location as all presentation downloads. It will be posted the day after each monthly presentation.