Interventional Neuroradiology. & Stroke INR PROCEDURES INR PROCEDURES. Dr Steve Chryssidis. 25-Sep-17. Interventional Neuroradiology

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1 Interventional Neuroradiology Interventional Neuroradiology & Stroke Dr Steve Chryssidis Interventional Neuroradiology (INR) is a subspecialty within Radiology INR -- broadly defined as treatment by endovascular access for the purpose of delivering therapeutic drugs and devices Interventional Neuroradiology Interventional Neuroradiology INR is a hybrid of Neurosurgery Interventional Radiology Neuroradiology Growing evidence in favour of INR techniques Minimally invasive may be preferable for medically complex patients The sub-speciality has established its role in the management of neurovascular conditions INR PROCEDURES INR PROCEDURES Endovascular aneurysm coiling is an example of this minimally invasive trend Mostly performed under GA However, stroke procedures mostly performed with sedation only 1

2 INR PROCEDURES INR PROCEDURES Procedures are performed: transfemoral (most commonly) transbrachial transcarotid Procedures may be elective or emergency Aneurysmal subarachnoid haemorrhages best treated within 24hrs Acute stroke interventions within anterior circulation require treatment within 6hrs of onset -- the sooner the better! IV thrombolysis must be commenced within 4.5hrs of onset One of Australia s biggest killers and a leading cause of disability Kills more women than breast cancer and more men than prostate cancer In 2017 there will be almost 56,000 new and recurrent strokes one stroke every 9 mins More than 80% of stroke can be prevented In 2017 there will be more than 475,000 people living with the effects of stroke Around 30% of stroke survivors are under 65yrs 65% of stroke survivors suffer a disability which impedes their ability to carry out daily living activities unassisted Financial cost of stroke in Australia ~$5 billion each yr In 2015, funding for stroke research through NHMRC was 4.1% of total investment in medical research 40% of people who have a TIA will have a stroke Nearly half of all strokes occur within the first few days after a TIA Symptoms for TIA are the same as for a stroke * Stroke Foundation * Stroke Foundation 2

3 FAST FACE: Check face. Mouth dropped? ARMS: Can they lift both arms? SPEECH: Slurred speech? Do they understand you? TIME: Time critical! Call 000 For every 30 min delay in reperfusion 10% drop in probability of a good clinical outcome HDU/ICU Ambulance Service Emergency Service Interventional N euroradiolog y + Anaesthesia Diagnostic Radiolog y Stroke Team N eurologists & N ursing team m em bers 3

4 Infarct core Ischaemic penumbra Comprehensive care. Uncompromising quality. drjones.com.au Comprehensive care. Uncompromising quality. drjones.com.au 4

5 CLINICAL SCENARIO 40yo man Day 3 post chest wall surgery Sudden onset left hemi-plegia, dysarthria and confusion Entirely unexpected Comprehensive care. Uncompromising quality. drjones.com.au Comprehensive care. Uncompromising quality. drjones.com.au 5

6 Cerebral Infarct Onset Patient comfort and haemodynamic stability crucial Post revascularisation blood pressure control imperative GA or sedation -- time limitations Need to be organised and efficient Infarct Core Penumbral Tissue 6

7 Cerebral Infarct 6hrs Cerebral Infarct 24hrs Infarct Core Infarct Core Penumbral Tissue Penumbral Tissue Cerebral Infarct Without Treatment STUDIES SUMMARY STUDIES STUDIES MR CLEAN ESCAPE SWIFT PRIME EXTEND IA REVASCAT 7

8 STUDIES STUDIES Study protocols all emphasised fast treatment All used CT (some used MRI) criteria to include patients with target large vessel occlusions these patients are most likely to benefit from endovascular therapy The studies used second-generation neurothrombectomy devices better recanalisation rates and lower complication rates than first gen devices/techniques STUDIES STUDIES STUDIES STUDIES Most common large vessel occlusion site was middle cerebral artery (MCA M1 segment) followed by terminal intracranial segment of the internal carotid artery Times to access patient s vessels ranged from 2hr 20min to 4hr 30min Treatment outcomes measured using modified Rankin Scale (mrs) at 90 days (mrs 0-6). Target range = mrs 0-2 at 90 days. 8

9 STUDIES STUDIES Reduced chance of disability at 90days in patients assigned to thrombectomy vs control arm Number needed to treat to reduce mrs by at least 1 point was 2.6 Proportion of patients with mrs 0-2 at 90 days was higher in endovascular thrombectomy population than control population STUDIES STUDIES STUDIES STUDIES No statistically significant difference in: Symptomatic intracranial haemorrhage Parenchymal haematoma Mortality When comparing treatment vs control arms Direction of effect favoured endovascular treatment across all strata Effects favouring intervention were significant in: Patients older than 80yrs Those randomised more than 300min after symptom onset Those not receiving IV alteplase (clot buster) 9

10 STUDIES STUDIES Patients >80yrs assigned to thrombectomy had slightly reduced risk of death Whilst worse clinical outcome with older age and higher NIHSS score (stroke severity score), intervention provided a consistent treatment benefit across the entire age range Modern endovascular therapy provides at least 50% chance of improving clinical outcome compared to medical therapy alone For every 100 patients treated: 38 will have LESS DISABLED outcome than those who receive medical treatment only 20 MORE will achieve functional independence as a result of treatment (mrs 0-2) STUDIES STUDIES Endovascular reperfusion should be pursued for large vessel occlusions irrespective of eligibility for alteplase Consistent benefit for endovascular treatment on disability across all age groups, including octogenarians STUDIES Size of pretreatment infarction on initial CT is a critical determinant of clinical outcome Patients with signs of large infarct on baseline imaging are excluded Intervention even benefited patients randomised later than 300min from stroke onset STUDIES Stent retrievers were the main device across all five trials Treatment benefit most robust with this technology 71% had reperfusion to at least half of affected territory 10

11 STUDIES STUDIES Endovascular thrombectomy reduced disability for patients with large vessel anterior circulation ischaemic stroke Benefits seen across wide range of: age initial stroke severity irrespective of IV alteplase eligibility DAWN trial results released 2017 Trial findings presented at the European Stroke Organisation Conference (ESOC) 2017 Patients screened for inclusion if had a stroke that started within 6-24hrs of last seen well OR stroke with unknown time of onset 206 patients STUDIES When compared to medical management, treatment significantly: decreased post stroke disability and improved functional independence at 90days 1 in 2.8 patients treated with stent retriever within 24hrs of stroke saved from severe disability Independent data safety monitoring board recommended stopping study enrollment based on interim analysis (initially designed to enrol up to 500 patients!) STUDIES Treatment is expensive and has risks Consumables up to $12,000 Complications Up to 9% embolisation to new territory 5% vessel perforation 11

12 RISK FACTORS FOR SUCCESS TREATMENT GUIDELINES Symptom duration (<6hrs) Stroke severity Age Glucose HTN Clot location Collaterals General anaesthesia Operator experience Institutional infrastructure Revascularisation Patients should receive endovascular therapy if they meet the following criteria: Pre-stroke mrs 0 or 1 Receiving IV tpa ICA or MCA M1 clot (also Basilar artery) > 18 yrs NIHSS >/= 6 Groin puncture within 6hrs ( but may now be up to 24hrs in selected patients) THANK YOU 12