Acute brain vessel thrombectomie: when? Why? How? Didier Payen, MD, Ph D Université Paris 7 Département Anesthesiologie-Réanimation Univ Paris 7; Unité INSERM 1160 Hôpital Lariboisière AP-HParis
current standard therapy for acute ischemic stroke (AIS) is iv tpa tpa improves survival and functional outcomes when administered as early as possible after onset of ischemic stroke, use is limited by the narrow therapeutic time window(<4.5 hours) and by important CIs, (coagulopathy, recent surgery, or stroke or head injury within the past 3 months) as few as 10% of patients presenting with AIS can be eligible endovascular intervention can recanalize large arterial occlusions earlier and more frequently Whether this translates into more favorable clinical outcomes was assessed in RTs that evaluated outcomes of endovascular therapy vs intravenous tpa for ischemic stroke
Clinicians treating patients with hyperacute stroke will have many questions: Are the Data from RCTs Reliable? Who Should Undergo Thrombectomy? What Is the Latest Time Window for Thrombectomy? How Should Thrombectomy Be Delivered? How Many Patients Might Be Eligible for Thrombectomy? Which Hospitals Should Perform Thrombectomy? How Should Hyperacute Stroke Be Treated?
Time from onset stroke to groin puncture: 200 to 260 min
1. TICI grade 2b/3 recanalization was achieved in 59% to 88% of endovascularly treated subjects in the 5 stent retriever trials 2. Endovascular therapy was associated with a significant proportional treatment benefit across mrs scores (OR, 1.56; 95%CI, 1.14 2.13; P =.005) 31,8% 44,6% 3. No significant difference in rates of symptomatic intracranial hemorrhage within 90 days (5.7% v 5.1%) or all-cause mortality at 90 days (~16%) Functional Outcomes of Endovascular Therapy vs Standard Therapy. According to Badhiwala et al. Badhiwala JAMA. 2015;314(17):1832-1843
Conscious Sedation versus General Anesthesia for MT Complicated patients are excluded from MT studies Forest plot of meta-analysis results for good functional outcome (mrs </= 2) Compared with patients treated by using conscious sedation, patients undergoing general anesthesia had = higher odds of death (OR 2.59; 95% CI, 1.87 3.58) and respiratory complications (OR 2.09; 95% CI, 1.36 3.23) and lower odds of good functional outcome (OR0.43; 95% CI, 0.35 0.53) and successful angiographic outcome (OR0.54; 95% CI, 0.37 0.80). No difference in procedure time (P.28) was seen between the groups. Meta-analysis results: categoric outcomes Brinjikji AJNR Am J Neuroradiol 36:525 29 Mar 2015
Guidelines AHA/ASA 2015 (1) 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, occlusion of the ICA or proximal MCA (M1), age 18 years, NIHSS score of 6, ASPECTS of 6 and the treatment can be initiated (groin puncture) within 6 hours of symptom onset Reduced time before reperfusion is highly associated with better clinical outcomes Reperfusion TICI2b3 should be achieved as early as possible within 6 hours of stroke onset (effectiveness uncertain beyond 6 hours even for proximal occlusion) In carefully selected patients with anterior circulation occlusion who have contraindications to intravenous r-tpa, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable The use of MT may be reasonable for carefully selected 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 Powers et al Focused Update on Acute Ischemic Stroke and Endovascular Treatment. AHA/ASA Guidelines Stroke 2015
Guidelines AHA/ASA 2015 (2) MT could be reasonable for other specific patients (<18y, ASPECTS<6, NIHSS<6, prestroke mrs >1, etc.) Endovascular therapy with stent retrievers is recommended over intraarterial fibrinolysis as first-line therapy It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. The ultimate selection of anesthetic technique should be individualized on the basis of risk factors, tolerance of the procedure, and other clinical characteristics Emergency imaging of the brain is recommended before any specific treatment for acute stroke is initiated Patients should be transported rapidly to the closest available certified primary stroke center Powers et al Focused Update on Acute Ischemic Stroke and Endovascular Treatment. AHA/ASA Guidelines Stroke 2015
The future is ambulance-based TL and extended time window Trials aim to extend this time window to 6 12 h (POSITIVE) and 6 24 h (DAWN) with the use of perfusion imaging selection Ebinger M et al; JAMA 2014. 311 (16): 1622-31
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To conclude MT is a revolutionary treatment for Acute Stroke Time window is larger than for rtpa with less CIs Combination of the 2 methods has the best result Indications for MT might be enlarged GA vs CS is still debated: 2 trials are on going to solve the question Our data suggests that in most severe cases, GA might help if the patient is in ICU
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