Acute stroke update 2016 innovations in managing ischemic and hemorrhagic disease Christopher Koebbe, MD Endovascular Neurosurgeon Florida Spine Institute Director of Neurosciences Northside Hospital Overview of brain aneurysm treatment strategies preventing the wicked bleed Location and imaging Who should be treated? The clip vs coil debate The tools of the trade: Evolution of endovascular and surgical technologies The many faces of a brain aneurysm 1
SAH decision making: 67 yo HH3 with right ICA occlusion= 3 headed monster 2
Risk Factors for Aneurysm Growth Smoking!!! #1 risk for development and rupture Family History 17X increase rupture risk in small aneurysms (Stroke June 2009) Don t blame it on your loved one not AD Get an MRA/CTA if a first degree relative Bad Luck 80% of aneurysm patients have neither of the above Born with artery weakness? Warning signs of a brain aneurysm MOST headaches not due to aneurysms Worst headache of life Hit by a baseball bat Car ran over my head Head was in a vice clamp Additional warning signs Stroke signs Numbness Weakness Visual Changes Double vision Drooping eyelid 3
Treatment options Observation Sometimes it is safer to do nothing Coils vs. Clips debate 45 yo smoker grade 2 SAH ED considerations Postop lat view 4
Follow up views 3 and 6 months Occlusion Rates (Scale of Roy) Site Reported 1 Limited conclusions on occlusion because: 1. IntrePED focused on safety 2. Occlusion data was not required so many sites did not submit N=144 N=216 N=147 N=28 1. IntrePED Presentation by Dr. David Kallmes, SNIS Conference, July 28, 2013, 38 yo woman smoker dense perimesencephalic SAH initial angio negative 5
ISAT trial Lancet 2002 CLIP AND/OR COIL 1 st Level 1 evidence in favor of endovascular treatment in SAH patients Biased in that 6000 pts excluded due to lack of equipose MCA were clipped;basilar coiled A trial of pcom and acom treatments Primary outcome mrs3 6: 22% with endovasc vs 31% with surgery Rebleeding risk higher with endovascular (2 per 1276 pt years vs 0 per 1081) ISAT update: 5 yr results (Lancet Neurology 2009) Risk of rebleed (n=13) 10 endovascular vs 3 surgical (p=0.06) Primary outcome mrs 0 2 no longer significant Endovascular 83% vs neurosurgical 82% Risk of death significantly different 11% endovascular and 14% neurosurgical (p=0. 03) 6
44 yo man severe headaches and diplopia CN 3 and 6 palsies Mass effect in cavernous sinus 1 st device 7
2 nd device Distal access lost bailout time 3 rd and 4 th devices 8
Role of flow diverters in aneurysms with mass effect Hungary group (AJNR Mar 2013 epub) 30 aneurysms in 27 pts all >10mm Fu at 6 18 months MRI showed 27 collapsed completely and 3 got smaller 6 month angio showed 28 complete occlusion, 1 neck remnant, 1 residual filling Clinical outcomes Vision improved in 5 of 6 (2 pts worsened in short term) Diplopia full resolution in 7/10 and partial 3/10 Hemiparesis due to brainstem compession improved in 1/1 at 6 months 63 yo VA pt vision loss over 5 monthslight perception only 9
What would you do if it was your loved one? Age The older you are the sooner something else may take your life Aneurysm size Bigger is not always better Size ratio may be better predictor (Stroke 5/10) Location Posterior circulation is worse Aneurysm shape Presence of risk factors SMOKING RR 3.0 in Finnish data JNS 2000 Family history of rupture Stroke Epidemiology 10
DEVASTATING EFFECTS OF STROKE Stroke causes 40% of its victims to require some form of skilled nursing care One in every three people will have a stroke in their lifetime Four of five families in the USA will somehow be touched by stroke FEWER than half of individuals over 50 years of age know what stroke is!!! 42 yo woman NIHSS 29 presents 45 minutes from onset to ED Healthy no risk factors present IVTPA given NIHSS to 14 CTA shows occluded left MCA MRI diffusion minimal infarct volume MRA shows persistent MCA occlusion 11
The gold standard of acute stroke therapy: NINDS IV rt PA Study Part 1 Primary Outcome (24 hrs) NS % patients 4 pt improvement in NIHSS 70 60 50 40 30 20 39% 47% 10 0 placebo tpa NEJM 1995; 333:1581-1587 Role of IA therapies in acute stroke?? Expand time window for therapeutic options Greater chance for successful vessel recanalization Reduce risk of hemorrhagic conversion Salvage all possible ischemic brain tissue 2013 was a bad year old devices, delays in thrombectomy Mechanical thrombolysis: Merci Retrieval System International, multicenter, prospective trial N=131, mean NIHSS 19 Within 8 hours of symptom onset Included patients who failed IV tpa Clinical Results Recanalization rate: 57% device alone;70% device and IA tpa mrs 0 2: 36% Symptomatic ICH 10% 12
IMS 3 results timing is everything Technology evolves 89 yo WWII purple heart recipient H/O Afib, pacemaker, 2 strokes over past year Eliquis stopped for treatment of bleeding GI ulcer one week ago Tele neurology consulted unable to give IV TPA Presents NIHSS 16 four hours after onset after transport to Northside What next? 13
89 yo WWII purple heart CT PERFUSION Emergent transport to angio suite conscious sedation Stent treiver deployed across thrombus 14
25 minutes from groin puncture after slow pull 5 hours post onset 2015 ISC meeting was a much better time MR Clean data 15
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HCA protocol helpful hints Noncontrast head ct ASAP Tele neurology evaluation for IVTPA decision DON T be afraid to ask tele neurologist if candidate for intra arterial therapy DON T delay transfer to Northside for additional imaging Time to reperfusion determines outcome!! SAH guidelines helpful hints Consider LP in WHOL cases and no blood on head CT Don t hesitate to get CT angiogram in suspected cases Keep SBP<140, can give nimitop 60 mg po if available Recommend Keppra bolus (500 or 1000 mg IV) Early airway control as necessary Transfer to Northside for comprehensive neurovascular service available 24/7 My cell is 210 788 4092 18