FUTURE DIRECTIONS OF STROKE CARE
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1 FUTURE DIRECTIONS OF STROKE CARE Jawad F. Kirmani MD Director Stroke & Neurovascular Center New Jersey Neurological Institute Stroke & Neurovascular Center of New Jersey Mohammad Moussavi, MD, Spozhmy Panezai, MD, Siddharat Mehta, MD, Daniel Korya, MD, Mohammad Hussein, MD Florence Chukwuneke RN, Martin Gizzi MD, PhD 12/06/2013
2 OUTLINE Concept #1 Gotta have a Window! Concept #2 Bridges are Useless! Concept #3 Different Folks Same Strokes! Concept #4 Never mix your Meds! Concept #5 Stenting is for the Heart! Cases Conclusion
3 Concept #1 : Gotta have a window! Acute Stroke intervention has traditional Time Windows
4 Intravenous Thrombolysis 624 patients with ischemic stroke within 3 hours Intravenous tpa (0.9 mg/kg) vs placebo tpa Follow-up 3 months placebo Favorable outcome 42% 27% Symptomatic ICH 6.4% 0.6% Death at 3 month 17% 21% NINDS trial N Engl J Med Dec 14;333(24):
5 Intravenous Thrombolysis 700 patients with ischemic hemispheric infarct <6 hours of onset Favorable outcome rt-pa 0.9 mg/kg vs placebo Follow-up 90 days rtpa placebo 40.3% 36.6% ECASS 2 Any parenchymal hemorrhage 11.8% 3.1%
6 Intravenous Thrombolysis 821 patients with ischemic stroke within 3 to 4.5 hours Intravenous tpa (0.9 mg/kg) vs placebo 3 months follow-up tpa placebo Favorable outcome 52% 45% Symptomatic ICH 2.4% 0.2% Death at 3 month 7.7% 8.4% ECASS 3
7 IA 180 patients with occlusion of MCA within 6 hours of onset IA Prourokinase (9mg) Vs. Placebo Follow-up 3 months Prourokinase Placebo Recanalization Hemorrhagic transformation 66% 18% 10% 2% Favorable outcome 40% 25% PROACT - II Prolyse in Acute Cerebral Thromboembolism Trial Stroke. 1998;29:4-11.
8 IA 114 patients with occlusion of MCA within 6 hours of onset-japan-2007 IA Urokinase Vs. Placebo Follow-up 3 months Urokinase Placebo Recanalization Symptomatic ICH 73% 9% 2% Favorable outcome 49% 39% MELT Stroke. 2007;38:
9 Mechanical 151 patients with occlusion of large intracranial vessels within 8 hours of onset and ineligible for IV-tPA Merci Retriever device Follow-up 3 months MERCI-1 NINDS - tpa Recanalization Symptomatic ICH 46% 7.8% 6.4% Favorable outcome 28% 30% >Placebo MERCI-1 Stroke. 2005;36:
10 125 patients with occlusion of large intracranial vessels within 8 hours of onset and ineligible for IV-tPA Mechanical Penumbra system Follow-up 3 months Penumbra NINDS - tpa Recanalization Symptomatic ICH 82% 11.2% 6.4% Favorable outcome 25% 42% PENUMBRA Stroke. 2009;40:
11 164 patients with occlusion of large intracranial vessels +/- lytics Merci Retriever device-8h Follow-up 3 months MULTI-Merci (L5 & others) NINDS - tpa Recanalization 68% Symptomatic ICH 10% 6.4% Favorable outcome 36% 42% Mortality 34% 21% MULTI-MERCI Stroke. 2008; 39:
12 60 patients with occlusion of large intracranial vessels +/- lytics Trevo Retriever device-8h Follow-up 3 months Trevo NINDS - tpa Recanalization Symptomatic ICH 92% 5% 6.4% Favorable outcome 55% 42% TREVO Presented by: Wahlgren M, International Stroke Conference, 2012, New Orleans
13 113 patients with occlusion of large intracranial vessels +/- lytics-8h Solitaire vs Merci Retriever device Follow-up 3 months Salitaire Merci Recanalization w/o symptomatic ICH 61% 24% Recanalization 83% 48% Symptomatic ICH Good mental/motor functioning 1.7% 11% 58% 33% Mortality 17% 38% SWIFT International Stroke Conference (ISC) 2012: Abstract LB8. Presented February 3, 2012.
14 BUT WHAT ABOUT MR. H? 71 y.o. AAM HTN, Cigs, Et-OH Presented 17 hours after onset of progressive Aphasia Right Homonymous Hemianopsia Right sided Hemiparesis Initial NIHSS 17
15 CLINICAL COURSE Initial CT Normal? Subtle Early changes Admitted Pending MRI results Loaded with Plavix 300mg Fluid Bolus to elevate 24 hours NIHSS=24 Somnolent Right Hemineglect
16 MRI Small deep DWI Lesion Large PWI Lesion
17 ANGIOGRAM
18 ANGIOGRAPHIC RESULT
19 OUTCOME Improvement began within 15 minutes 4hrs Post NIHSS=6 DWI Same PWI Normal POD#3 D/C to Home NIHSS=3
20 RESULTS-SNC NJ DATA 40 Patients 24 Men Mean age 62.5±15years Range Average Time-to-Tx 12.2±14hrs Range 8-68hrs Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
21 RESULTS Mean NIHSS 19.5±6.1 Range 7-28 Vessel Occlusion MCA 15 ICA 5 Tandem ICA+MCA 12 BA 8 Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
22 TREATMENT IA Lysis/IA GIIb IIIa 17 Alone 4 Embolectomy 19 Alone 8 PTA/Stenting 16 Alone 5 Combination 22 Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
23 RESULTS- RECANALIZATION TIMI 2/3 82.5% TIMI % Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
24 RESULTS- ADVERSE EVENTS Symptomatic ICH 2 (5%) All ICH 6 (15%) Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
25 RESULTS- CLINICAL OUTCOMES NIHSS D/C 8.0±6.6 days 5(12.8%)
26 RESULTS- FOLLOW-UP Death 10% mrankin % Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, Abou-Chebl A, Baxter B, Levy EI, Barreto A, Nogueira RG. Stroke Aug;42(8): doi: /STROKEAHA Epub 2011 Jul 21. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients.
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37 CONCEPT # 2 BRIDGING IS USELESS! BRIDGING from Intravenous to Neurointerventional therapeutic options may not be a helpful strategy for stroke patient treatment.
38 81 patients with occlusion of MCA within 3 hours of onset IV t-pa followed by Angiograpy, then +/- IA t-pa or EKOS Follow-up 3 months IMS-2 NINDS - tpa Recanalization 60% Symptomatic ICH 10% 6.4% Favorable outcome 46% 42% Recanalization of EKOS vs IA-tPA 73% vs 56% IMS -11 Stroke. 2007; 38:
39 Broderick JP et al. N Engl J Med 2013;368:
40 IMS III Joseph P. Broderick, M.D., Yuko Y. Palesch, Ph.D., Andrew M. Demchuk, M.D., Sharon D. Yeatts, Ph.D., Pooja Khatri, M.D., Michael D. Hill, M.D., Edward C. Jauch, M.D., Tudor G. Jovin, M.D., Bernard Yan, M.D., Frank L. Silver, M.D., Rüdiger von Kummer, M.D., Carlos A. Molina, M.D., Bart M. Demaerschalk, M.D., Ronald Budzik, M.D., Wayne M. Clark, M.D., Osama O. Zaidat, M.D., Tim W. Malisch, M.D., Mayank Goyal, M.D., Wouter J. Schonewille, M.D., Mikael Mazighi, M.D., Ph.D., Stefan T. Engelter, M.D., Craig Anderson, M.D., Ph.D., Judith Spilker, R.N., B.S.N., Janice Carrozzella, R.N., B.A., R.T.(R.), Karla J. Ryckborst, R.N., B.N., L. Scott Janis, Ph.D., Renée H. Martin, Ph.D., Lydia D. Foster, M.S., Thomas A. Tomsick, M.D., for the Interventional Management of Stroke (IMS) III Investigators N Engl J Med Volume 368(10): March 7, 2013
41 Broderick JP et al. N Engl J Med 2013;368:
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43 Primary and Secondary Safety End Points. Broderick JP et al. N Engl J Med 2013;368:
44 Distribution of Modified Rankin Scores, According to Study Group and Score on the National Institutes of Health Stroke Scale (NIHSS). Broderick JP et al. N Engl J Med 2013;368:
45 Adjusted Relative Risk for Predefined Subgroups, as Assessed According to the Primary Outcome of a Modified Rankin Score of 0 to 2 at 90 Days. Broderick JP et al. N Engl J Med 2013;368:
46 WHAT ABOUT MS. L 50 y/o F came to a Community Hospital within an hour of stroke onset affecting the left side of her body, Dysarthria. NIHSS of 7 IVtPA given with transient improvement to NIHSS of 4 Worsened to 7 within a couple of hours Then NIHSS to 10 and after 24 hours, we get a call!
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52 CONCEPT # 3 DIFFERENT FOLKS DIFFERENT STROKES Not all strokes are alike. Imaging guides you to treatment decision nodes in various possible directions.
53 51 year old female presented with an 18 hour history of left facial droop, left upper extremity hemiplegia and lower extremity hemiparesis (NIHSS 7). CT head showed right basal ganglia hypodensity. Patient was out of time window for intravenous rt-pa or intra-arterial intervention.
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58 CONCEPT # 4 DON T MIX YOUR MEDS Thrombolytics can never be combined with antiplatelet agents, GIIb IIIa inhibitors, with additional thrombolytics, levonox, heparin. List goes on
59 SAFETY OF IA BOLUS AND IV INFUSION OF EPTIFIBATIDE FOLLOWING IV TPA 28 patients, 92% recannalization rates. 3.6% Major Adverse Effects (n=1) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Complete Recannalization Immediate Improvement Symptomatic Hemorrage Partial Recannalization Asymptomatic Hemorrage Good Outcome ISC 2012, New Orleans Moussavi M. et al
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66 100% SASI I 80% Stenting for Acute Stroke Intervention following full dose IVtPA Phase I Study IVtPA followed by Acute Stenting for a selected patient group 23 patients, 87% recannalization rates. 4.3% Major Adverse Effects (n=1) 60% 40% 20% 0% Early Clinical Improvement Asymptomatic ICH Symptomatic ICH Partial Recannalization Complete Recannalization ISC 2012, New Orleans Kirmani JF. et al
67 CONCEPT #5: STENTING IS FOR THE HEART Intracranial stenting should not be tried!
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75 CONCLUSION Appropriately selected patients with salvageable brain tissue may be treated safely regardless of myths surroundings rigid stroke paradigms. This where the future of acute stroke care is going to lead us to. Thorough Evaluation of Pathophyisolgy Arterial Anatomy Brain Substrate
76 A foolish consistency is the hobgoblin of little minds - Ralph Waldo Emerson
77 Stroke & Neurovascular Center of New Jersey
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