Endovascular Treatment Updates in Stroke Care

Transcription

1 Endovascular Treatment Updates in Stroke Care Autumn Graham, MD April 6-10, 2017 Phoenix, AZ

2 Endovascular Treatment Updates in Stroke Care Autumn Graham, MD Associate Professor of Clinical Emergency Medicine Department of Emergency Medicine Medstar Georgetown University Hospital Medstar Washington Hospital Center Washington, DC Objectives Review 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment Identify the patients most likely to benefit from endovascular treatment Discuss indications for and barriers to transferring a patient in need of endovascular treatment Describe controversies around endovascular vs medical management of the patient with acute stroke 55 miles 1

3 NNTB 3.9 NNTH 71 NNTB 4.0 NNTH 37 NNTB 6.5 NNTH 33 NNTB 17 NNTH 13 Number of patients who benefit and are harmed per 100 patients treated with IV tpa in each time window Lansberg et al. Treatment Time Specific Number Needed to Treat Estimates for Tissue Plasminogen Activator Therapy in Acute Stroke Based on Shifts Over the Entire Range of the Modified Rankin Scale. Stroke

4 4% greater odds of walking independently at discharge 3% greater odds of being discharged home 4% lower odds of experiencing symptomatic ICH Intravenous t PA within 3 hrs of onset of ischemic stroke improved clinical outcomes at 3 months 4.5 Hrs 3

5 Onset 3 hrs 4.5 hrs 6 hrs 24 hrs IV tpa How can we impact patients in this time frame? Key Stroke Concepts Infarct Core Dead Brain Irreversible Damage Penumbra Hibernating Brain Potentially Reversible Injury Blood Brain Injury Risk of hemorrhagic conversion with reperfusion Stroke October

6 Published in RCT No clear benefit over standard intravenous tpa Patient Selection Lack of image based patient selection 1 st Generation Devices 5

7 Approved by FDA in 2004 for 8 hr from symptom onset Recanalization rates 46 48% Approved by FDA 2010 for large vessel occlusion with symptoms < 8 hr Penumbra Privotal Stroke Trial I. The penumbra privotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke; J Cereb Circ. 2009; 40 (8) 2761 Little emphasis on hospital work flow = longer treatment times 6

8 Recanalization rates 27% 48 % December 17, 2014 MR CLEAN Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke (Netherlands) STENT RETRIEVER Recanalization 59% 88% 7

9 500 patients enrolled at 16 medical centers Characteristics Intervention (233) Control (267) Age 65 (55 to 76) 66 (56 to 76) Male Sex 135 (58%) 157 (59%) NIHSS 17 (14 to 21) 18 (14 to 22) Treatment with IV tpa 203 (87%) 242 (91%) ASPECTS score 9 9 Berkhemer et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM Modified Rankin Scale Scores at 90 Days in the Intention to Treat Population. 33% 19% Berkhemer OA et al. N Engl J Med 2015;372: MR CLEAN: Adverse Events Serious Adverse Events Parenchymal Hemorrhage Type 2 Intervention Control 14 (6.0%) 14 (5.2%) Hemicraniectomy 14 (6.0%) 13 (4.9%) New CVA in Different Vascular Territory 13 (5.6%) 1 (0.4%) Berkhemer et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM

10 MR CLEAN: Adverse Events Serious Adverse Events Parenchymal Hemorrhage Type 2 Intervention Control 14 (6.0%) 14 (5.2%) Hemicraniectomy 14 (6.0%) 13 (4.9%) New CVA in Different Vascular Territory 13 (5.6%) 1 (0.4%) Berkhemer et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM SWIFT PRIME REVASCAT 9

11 EXTEND IA ESCAPE New standard of care: Endovascular therapy for Anterior LVO strokes (2015) Consistently positive endovascular treatment trials for patients treated < 6h REVASCAT 10

12 Trial N Median Onset to Groin Puncture MR CLEAN hrs 20 min ESCAPE hrs 4 min EXTEND IA hrs 30 min SWIFT Prime hrs 4 min REVASCAT hrs 29 min 90 day mrs 0 2 Risk Reduction, NNT 33% vs. 19%, % vs. 29%, % vs. 40%, % vs. 35%, % vs 28%, 6.5 Death Risk Reduction 18% vs. 19% 10% vs. 19% 9% vs. 20% 9% vs. 12% 18% vs 15% 1 Berkhemer, O. A. et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM Goyal, M. et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. NEJM Campbell, B. C. et al. Endovascular Therapy for Ischemic Stroke with Perfusion Imaging Selection. NEJM Saver et al. Stent Retriever Thrombectomy after Intravenous t PA vs. t PA Alone in Stroke. NEJM Jovin, T. G.. et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. NEJM Onset 3 hrs 4.5 hrs 6 hrs 24 hrs IV tpa Mechanical Embolectomy vs. Medical Management?? Mechanical Embolectomy (Stent Retriever) Correct Patient Premorbid functional status? Co morbidities? Risk of complications? Tolerate stress of major stroke? Capacity to recover? Ability to participate in rehabilitation? 11

13 FAST ED FAST ED NIHSS Facial Palsy Normal or minor paralysis Partial or complete paralysis Arm Weakness No drift 0 0 T stands for time Requires validation studies Drift or some effort against gravity No effort against gravity or no movement Speech changes Absent 0 0 Mild to moderate 1 1 Severe, global aphasia, or mute Eye Deviation Absent 0 0 Partial 1 1 Lima et al. Field Assessment Stroke Triage for Emergency Destination; a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke. August 2016 Forced deviation 2 2 Denial/Neglect Absent 0 0 Extinction to bilateral simultaneous 1 1 stimulation Does not recognize own hand or 2 2 orients only to one side of the body Low Risk Intermediate Risk 0 9% 1 14% 2 30% 3 33% 4 59% 5 69% 6 84% 7 77% 8 83% 9 80% High Risk Lima et al. Field Assessment Stroke Triage for Emergency Destination; a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke. August 2016 Telemedicine Cleveland Clinic OHSU Decreases time to tpa Similar safety as Primary Stroke Centers (2-7%) Medstar Health MI2 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke

14 Advanced Imaging Endovascular Capabilities Intravenous tpa Correct Hospital The Telegraph, June 3, 2016 Acute Stroke Ready Hospital Primary Stroke Center Acute Stroke Ready Hospital Comprehensive Stroke Centers Primary Stroke Center Primary Stroke Center Acute Stroke Ready Hospital Acute Stroke Ready Hospital 13

15 Community Hospital Non contrast Head CT ASPECTS scoring system MCA 1 point subtracted from 10 for early ischemic changes in each of the defined areas Higher ASPECTS score (8 10) = benefit from IV thrombolysis We use cutoff of > 6 Intravenous tpa Comprehensive Stroke Center 55 miles CT Angiography Head Favorable Ischemic Pattern Cranial MRA Small core Large penumbra 14

16 SMART Study % of patients treated 60 min Lean process interventions implemented 1st half nd half st half nd half fold increase! (p= ) Shah S, Luby M, Poole K, Hsia AW. Neurology Jun 16;84(24): yo,female with atrial fibrillation develops acute onset L sided weakness Patient drove to work in the morning and walked into the office. 07:25 Symptom onset 07:49 07:43 Code One called At 07:25, as she was talking to her co workers, she started to have slurred speech and developed L sided weakness a co worker caught her before she fell to the floor. A co worked called 911 despite her protest and she was brought to the MWHC ED by EMS. NIHSS = 7 Patient Arrival in MWHC ED A stat MRI is obtained. 15

17 Brain MRI and MRA Timeline 07:49 08:51 07:43 08:10 07:25 Symptom onset Code One called MRI Patient Arrival in MWHC ED IV tpa bolus plus infusion Cerebral Angiogram: Injection of the Right Internal Carotid Artery 16

18 Endovascular Therapy: Clot retrieved Cerebral Angiogram: Right ICA Injection Post Embolectomy TICI 3 (complete recanalization & reperfusion) At 3 hours from symptom onset Timeline 07:49 08:51 07:43 08:10 09:30 10:25 07:25 LSN and symptom onset Code One called Patient Arrival in MWHC ED MRI IV tpa bolus plus infusion IR groin puncture Clot removed 17

19 Serial Brain MRIs (Enrolled NIH Natural History of Stroke Study) Post IR DWI 24h DWI 5d FLAIR Patient discharged home on Hospital Day #3 NIHSS= update to 2013 AHA/ASA Guidelines Patients eligible for intravenous r tpa should receive intravenous r tpa even if endovascular treatments are being considered (Class I; Level of Evidence A Unchanged from the 2013 guideline) Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria: (Class I; Level of Evidence A New recommendation) Prestroke mrs score 0 to 1 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 Neuroprotection Extending the viability of the penumbra 18

20 Improve procedural first pass recanalization success Stenting? tenecteplase vs alteplase Better recanalization? Less ICH? 19

21 Procedural sedation better than General anesthesia for endovascular treatment? Can we extend the endovascular window? DEFUSE 3 Endovascular therapy vs. Medical management in the extended time window (6 16h) Sonolysis 20

22 Intravenous injection of iron nanoparticles? Take home points Time is still brain! We are moving toward neuroimaging driven patient selection Large vessel occlusions can re canalize with tpa but often don t Acute intervention should be pursued aggressively if: Large vessel occlusion Able to achieve groin puncture in 6 hrs for anterior circulation strokes Able to achieve groin puncture in 24 hours for posterior circulation strokes Questions? autumngraham@medstar.net Special Thanks Dr Amie Hsia Dr Richard Benson 21