SlideShare ist ein Scribd-Unternehmen logo
1 von 56
Downloaden Sie, um offline zu lesen
Audit/Research projects
July-December 2013.
Dr Wahid Altaf
Dr Sinead Galvin
Stroke
• Sudden death of cells
due to lack of oxygen.
• Manifesting as focal or global disturbance of
cerebral function lasting for more than twenty
four hours or leading to death.
• Survival of brain cells depends on time since
lack of oxygen.
Thrombectomy for ischemic stroke and anaesthesia
Stroke in Ireland
• Annual number of stroke patients in Ireland is
around 10,000.87% ischemic stroke.
• Annual number of deaths from stroke is 2000.
• Number of disabled patients secondary to
stroke around 30,000.
Risk factors for Ischemic stroke
•
•
•
•

Non-Modifiable
Age
Male sex
Race
Inheritance

•
•
•
•
•
•
•

Modifiable
Hypertension
Daibetes Mellitus
Cardiac disease (AF)
Cigarette smoking
Obesity
Increase homocysteine
Inc Cholesterol.
Diagnosis and treatment
• Its early diagnosis is important as its treatment is dependent on
the time elapsed since the onset of the symptoms. Delay in
diagnosis and treatment translates into increased neuronal loss
and thereby increased morbidity.
• Reperfusion remains the mainstay of acute ischemic stroke
treatment .
Time is Brain!!!!
• The average duration of
non-lacunar stroke evolution
is 10 hours (range 6 to 18
hours), and the average number of neurons in the
human forebrain is 22 billion.
• In each minute, 1.9 million neurons, 14 billion
synapses, and 12 km (7.5 miles) of myelinated fibers
are destroyed.
• Compared with the normal rate of neuron loss in
brain aging, the ischemic brain ages 3.6 years each
hour without treatment.
Time is Brain!!!!!
Treatment options available.
• IV rtPA therapy.
• Mechanical clot disruption with IAT.
• Thrombectomy.
THROMBUS
Mechanical thrombectomy

• Recanalization by mechanical thrombectomy
may occur due to combination of thrombus
fragmentation, thrombus retrieval, and
enhancement of fibrinolytic penetration.
• FDA cleared many devices for recanalization
of arterial occlusion in patients with ischemic
stroke.
The Evidence ????
• NINDS

iv tpa <3hours.

• ECASS III

iv alteplase 3-4.5 hours.

• PROACT II ia pro uk <6hours.
• MERCI

thrombectomy, 8hours.
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
General anesthesia for Intervention in
Stroke- Intra-arterial thrombolyis and
Mechanical thrombectomy in
Beaumont Hospital
Background
• Avoid anesthesia
Speed of whole process
Avoid anesthetic drug effectshypotension or effect on cerebral activity
• Need for anesthesia can’t be ignored.
• Retrospective review on type and number of
patients who got general anesthesia during last
three years for clot retrieval in radio-intervention
suite of Beaumont hospital.
• Identify demand, issues and future.
Clot retrieval in Beaumont Hospital
from April 2010 to Sept 2013.
• Total number of cases done 107.
Admission route
GA patients admission route
Distribution in 24 hours
Demographics
Male

56

Female

51

Age yrs (Average)

26-87 (62)
Demographics of patients for GA
Male

5

Female

7

Age years (Average)

32-73(55)
Overall Risk factors
Risk factor

Number of patients

High blood pressure

40

High cholesterol

18

Previous CVA

11

Ischemic heart disease

12

Atrial Fibrillation

26

Diabetes Mellitus

6

Smoking

20
Risk factors in GA patients
Risk factor

Number of patients

Hypertension

6

Ischemic heart disease

2

Atrial fibrillation

2

Smoking

1

Dyslipidemia

3
Stroke scale of patients (NIHSS)
NIHSS at presentation of all
patients.
NIHSS at presentation of GA
patients
Stroke characteristicsVessel involved
Stroke characteristics

Number of patients

Right sided

51

Left sided

56

Middle cerebral artery M1

59

Middle cerebral artery M2

13

Internal carotid artery

35

Basilar artery

5

Multiple vessels

42
Stroke characteristic of GA patients
Vessel Involved
Stroke characteristics

Number of patients

Right

8

Left

4

Internal carotid artery

6

Middle cerebral artery M1

6

Vertebral artery

1

Basilar artery

1
Planned Vs Rescue GA
IV Thrombolysis pre procedure
IV Thrombolysis before GA.
Hemodynamic parameters in GA
patients during the procedure
Parameter

Values Range (Average) mmHg

Systolic BP

100-140 (120)

Diastolic BP

60-90 (65)

Mean BP

73-106 (83)
Vasopressors used to maintain
blood pressure in GA patients
Complications
Complication

Number of patients

Procedural complications

15

Haemorrhage

28

Clinically significant haemorrhage

12
ICU Admission post procedure of
GA patients
MRS at 3 months.
MRS of GA patients
Prognosis overall
Prognosis of GA patients
Prognosis with intra-op
Blood pressure
Mean Arterial BP
(mmHg)

Survived

Dead

Unknown

< or= 80

1

4

1

>80

5

1

0
Issues important to us.
•
•
•
•

Increasing demand over the years.
Out of hours service needed.
High ASA grade of these patients.
Failed IV thrombolysis before clot retrieval and
consequences thereof.
• Internal carotid and middle cerebral artery
involvement in majority.
• Hemodynamic parameters to target/Blood glucose
control and means to achieve the same/maintaining
normothermia.
• Need for ICU/Ventilation post procedure.
Future
• Our demand to provide anesthesia for sick
patients may increase with time.
• Develop standard procedures and protocols.
• Canadian multi-centric trial for outcome from
clot retrieval.
• Clot retrieval in interventional cardiology.
Quality improvement maneuver
• Safer and standard anesthetic practice
Standard monitoring as per AAGBI.
IV canula with IV fluids running via 3 way
tap.
Anesthetic machine checked every day and
ready in high risk patients.
Emergency drugs/Airway tray ready to use.
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia
Thrombectomy for ischemic stroke and anaesthesia

Más contenido relacionado

Was ist angesagt?

Interventions in Stroke-Evidence based management
Interventions in Stroke-Evidence based managementInterventions in Stroke-Evidence based management
Interventions in Stroke-Evidence based managementDr Vipul Gupta
 
Endovascular treatment in acute cerebral ischemia
Endovascular treatment in acute cerebral ischemiaEndovascular treatment in acute cerebral ischemia
Endovascular treatment in acute cerebral ischemianikhilprerana
 
complications of thrombolysis (alteplase) in stroke
complications of thrombolysis (alteplase) in strokecomplications of thrombolysis (alteplase) in stroke
complications of thrombolysis (alteplase) in strokeNeurologyKota
 
Current status of stroke intervention
Current status of stroke interventionCurrent status of stroke intervention
Current status of stroke interventionNeurologyKota
 
Chronotropic Incompetence
Chronotropic Incompetence Chronotropic Incompetence
Chronotropic Incompetence Frank Meissner
 
Primary Percutaneus coronary intervention
Primary Percutaneus coronary interventionPrimary Percutaneus coronary intervention
Primary Percutaneus coronary interventionRamachandra Barik
 
Interventional+Procedures
Interventional+ProceduresInterventional+Procedures
Interventional+Proceduresdhavalshah4424
 
Brain death current concepts and legal issues in india
Brain death current concepts and legal issues in indiaBrain death current concepts and legal issues in india
Brain death current concepts and legal issues in indiaNeurologyKota
 
Medical Radiological and Surgical Management of Stroke
Medical Radiological and Surgical Management of Stroke Medical Radiological and Surgical Management of Stroke
Medical Radiological and Surgical Management of Stroke Manbachan singh Bedi
 
Percutaneous Coronary Intervention
Percutaneous Coronary InterventionPercutaneous Coronary Intervention
Percutaneous Coronary InterventionLadi Anudeep
 
Stroke thrombolysis protocol
Stroke thrombolysis protocolStroke thrombolysis protocol
Stroke thrombolysis protocolAnkit Gajjar
 
Myocardial perfusion imaging SPECT basics
Myocardial perfusion imaging SPECT basicsMyocardial perfusion imaging SPECT basics
Myocardial perfusion imaging SPECT basicsJennifer Gutiérrez
 
Cerebral Amyloid Angiopathy
Cerebral Amyloid Angiopathy Cerebral Amyloid Angiopathy
Cerebral Amyloid Angiopathy Ade Wijaya
 
The Intensive Care Management of Acute Ischemic Stroke
The Intensive Care Management of Acute Ischemic Stroke The Intensive Care Management of Acute Ischemic Stroke
The Intensive Care Management of Acute Ischemic Stroke Ade Wijaya
 
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...scanFOAM
 

Was ist angesagt? (20)

Interventions in Stroke-Evidence based management
Interventions in Stroke-Evidence based managementInterventions in Stroke-Evidence based management
Interventions in Stroke-Evidence based management
 
Endovascular treatment in acute cerebral ischemia
Endovascular treatment in acute cerebral ischemiaEndovascular treatment in acute cerebral ischemia
Endovascular treatment in acute cerebral ischemia
 
complications of thrombolysis (alteplase) in stroke
complications of thrombolysis (alteplase) in strokecomplications of thrombolysis (alteplase) in stroke
complications of thrombolysis (alteplase) in stroke
 
Management of no reflow
Management of no reflowManagement of no reflow
Management of no reflow
 
Current status of stroke intervention
Current status of stroke interventionCurrent status of stroke intervention
Current status of stroke intervention
 
Chronotropic Incompetence
Chronotropic Incompetence Chronotropic Incompetence
Chronotropic Incompetence
 
Primary Percutaneus coronary intervention
Primary Percutaneus coronary interventionPrimary Percutaneus coronary intervention
Primary Percutaneus coronary intervention
 
Interventional+Procedures
Interventional+ProceduresInterventional+Procedures
Interventional+Procedures
 
Brain death current concepts and legal issues in india
Brain death current concepts and legal issues in indiaBrain death current concepts and legal issues in india
Brain death current concepts and legal issues in india
 
Medical Radiological and Surgical Management of Stroke
Medical Radiological and Surgical Management of Stroke Medical Radiological and Surgical Management of Stroke
Medical Radiological and Surgical Management of Stroke
 
Percutaneous Coronary Intervention
Percutaneous Coronary InterventionPercutaneous Coronary Intervention
Percutaneous Coronary Intervention
 
Cerebral monitoring
Cerebral monitoringCerebral monitoring
Cerebral monitoring
 
Acute Coronary Syndromes
Acute Coronary Syndromes Acute Coronary Syndromes
Acute Coronary Syndromes
 
Brain death
Brain deathBrain death
Brain death
 
Stroke thrombolysis protocol
Stroke thrombolysis protocolStroke thrombolysis protocol
Stroke thrombolysis protocol
 
Myocardial perfusion imaging SPECT basics
Myocardial perfusion imaging SPECT basicsMyocardial perfusion imaging SPECT basics
Myocardial perfusion imaging SPECT basics
 
Cerebral Amyloid Angiopathy
Cerebral Amyloid Angiopathy Cerebral Amyloid Angiopathy
Cerebral Amyloid Angiopathy
 
Primary pci management
Primary pci managementPrimary pci management
Primary pci management
 
The Intensive Care Management of Acute Ischemic Stroke
The Intensive Care Management of Acute Ischemic Stroke The Intensive Care Management of Acute Ischemic Stroke
The Intensive Care Management of Acute Ischemic Stroke
 
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...
Anaesthesia for endovascular treatment in acute ischemic stroke - Mads Rasmus...
 

Andere mochten auch

What is a stent retreiver
What is a stent retreiverWhat is a stent retreiver
What is a stent retreiverAllan Tan
 
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...Sanjay Jaiswal
 
Push and Puff Technique for Mechanical Thrombectomy
Push and Puff Technique for Mechanical ThrombectomyPush and Puff Technique for Mechanical Thrombectomy
Push and Puff Technique for Mechanical ThrombectomyDr Vipul Gupta
 
IVtPA vs Mechanical thrombolysis, after 3-hours of stroke
IVtPA vs Mechanical thrombolysis, after 3-hours of strokeIVtPA vs Mechanical thrombolysis, after 3-hours of stroke
IVtPA vs Mechanical thrombolysis, after 3-hours of strokeDr Vipul Gupta
 
AHA/ASA Guidelines for Ischemic Stroke
AHA/ASA Guidelines for Ischemic StrokeAHA/ASA Guidelines for Ischemic Stroke
AHA/ASA Guidelines for Ischemic StrokeSun Yai-Cheng
 
Ken Faulder: Clot Retrieval and the Future of Stroke
Ken Faulder: Clot Retrieval and the Future of StrokeKen Faulder: Clot Retrieval and the Future of Stroke
Ken Faulder: Clot Retrieval and the Future of StrokeSMACC Conference
 
Recent evidence for mechanical thrombolysis
Recent evidence for mechanical thrombolysisRecent evidence for mechanical thrombolysis
Recent evidence for mechanical thrombolysisDr Vipul Gupta
 
Stroke guidelines, 2015
Stroke guidelines, 2015Stroke guidelines, 2015
Stroke guidelines, 2015Usama Ragab
 
Endovascular Introduction
Endovascular IntroductionEndovascular Introduction
Endovascular IntroductionAlvin Wang
 
Guidelines for management of acute stroke
Guidelines for management of acute strokeGuidelines for management of acute stroke
Guidelines for management of acute strokesankalpgmc8
 
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...Sun Yai-Cheng
 

Andere mochten auch (12)

What is a stent retreiver
What is a stent retreiverWhat is a stent retreiver
What is a stent retreiver
 
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...
Stroke thrombolysis Dr Sanjay Jaiswal,consultant nerologist,Jaiswal Hospital ...
 
Endovascular Prep Basic
Endovascular Prep BasicEndovascular Prep Basic
Endovascular Prep Basic
 
Push and Puff Technique for Mechanical Thrombectomy
Push and Puff Technique for Mechanical ThrombectomyPush and Puff Technique for Mechanical Thrombectomy
Push and Puff Technique for Mechanical Thrombectomy
 
IVtPA vs Mechanical thrombolysis, after 3-hours of stroke
IVtPA vs Mechanical thrombolysis, after 3-hours of strokeIVtPA vs Mechanical thrombolysis, after 3-hours of stroke
IVtPA vs Mechanical thrombolysis, after 3-hours of stroke
 
AHA/ASA Guidelines for Ischemic Stroke
AHA/ASA Guidelines for Ischemic StrokeAHA/ASA Guidelines for Ischemic Stroke
AHA/ASA Guidelines for Ischemic Stroke
 
Ken Faulder: Clot Retrieval and the Future of Stroke
Ken Faulder: Clot Retrieval and the Future of StrokeKen Faulder: Clot Retrieval and the Future of Stroke
Ken Faulder: Clot Retrieval and the Future of Stroke
 
Recent evidence for mechanical thrombolysis
Recent evidence for mechanical thrombolysisRecent evidence for mechanical thrombolysis
Recent evidence for mechanical thrombolysis
 
Stroke guidelines, 2015
Stroke guidelines, 2015Stroke guidelines, 2015
Stroke guidelines, 2015
 
Endovascular Introduction
Endovascular IntroductionEndovascular Introduction
Endovascular Introduction
 
Guidelines for management of acute stroke
Guidelines for management of acute strokeGuidelines for management of acute stroke
Guidelines for management of acute stroke
 
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...
2015 AHA/ASA Focused Update Guidelines for Acute Ischemic Stroke Regarding En...
 

Ähnlich wie Thrombectomy for ischemic stroke and anaesthesia

An analysis of outcomes of emergency physician
An analysis of outcomes of emergency physicianAn analysis of outcomes of emergency physician
An analysis of outcomes of emergency physicianDrArpan Chouhan
 
Stroke- Dr Harsimran Walia
Stroke- Dr Harsimran WaliaStroke- Dr Harsimran Walia
Stroke- Dr Harsimran Waliaharry11818a
 
Stroke- what's new
Stroke- what's newStroke- what's new
Stroke- what's newAhmad Shahir
 
SEMINAR CARDIAC TRANSPLANT.pptx
SEMINAR CARDIAC TRANSPLANT.pptxSEMINAR CARDIAC TRANSPLANT.pptx
SEMINAR CARDIAC TRANSPLANT.pptxNakkaSrikanth3
 
revasularisation of acute stroke.pptx
revasularisation of acute stroke.pptxrevasularisation of acute stroke.pptx
revasularisation of acute stroke.pptxvinay nandimalla
 
CVA BY DR.Manoj.pptx
CVA BY DR.Manoj.pptxCVA BY DR.Manoj.pptx
CVA BY DR.Manoj.pptxManoj Aryal
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complicationsFuad Farooq
 
SAH for Neurology Residents
SAH for Neurology ResidentsSAH for Neurology Residents
SAH for Neurology ResidentsDhaval Shukla
 
Cardiac Resynchronisation therapy.pptx
Cardiac Resynchronisation therapy.pptxCardiac Resynchronisation therapy.pptx
Cardiac Resynchronisation therapy.pptxAsfandiarAli1
 
TIA and stroke prevention
TIA and stroke preventionTIA and stroke prevention
TIA and stroke preventionLobna A.Mohamed
 
transient ischemic attacks- advances in diagnosis & mx
transient ischemic attacks- advances in diagnosis & mxtransient ischemic attacks- advances in diagnosis & mx
transient ischemic attacks- advances in diagnosis & mxdrwaque
 
Acute Coronary syndrome - Pharmacotherapy
Acute Coronary syndrome - PharmacotherapyAcute Coronary syndrome - Pharmacotherapy
Acute Coronary syndrome - PharmacotherapyAreej Abu Hanieh
 
Carotid+lecture+final[1].ppt
Carotid+lecture+final[1].pptCarotid+lecture+final[1].ppt
Carotid+lecture+final[1].pptssuser6fd387
 
Anesthesia for Carotid Surgery
Anesthesia for Carotid SurgeryAnesthesia for Carotid Surgery
Anesthesia for Carotid Surgeryssuser6fd387
 
How should recently symptomatic patients be treated urgent cea or cas
How should recently symptomatic patients be treated urgent cea or casHow should recently symptomatic patients be treated urgent cea or cas
How should recently symptomatic patients be treated urgent cea or casuvcd
 

Ähnlich wie Thrombectomy for ischemic stroke and anaesthesia (20)

An analysis of outcomes of emergency physician
An analysis of outcomes of emergency physicianAn analysis of outcomes of emergency physician
An analysis of outcomes of emergency physician
 
Stroke- Dr Harsimran Walia
Stroke- Dr Harsimran WaliaStroke- Dr Harsimran Walia
Stroke- Dr Harsimran Walia
 
Stroke- what's new
Stroke- what's newStroke- what's new
Stroke- what's new
 
SEMINAR CARDIAC TRANSPLANT.pptx
SEMINAR CARDIAC TRANSPLANT.pptxSEMINAR CARDIAC TRANSPLANT.pptx
SEMINAR CARDIAC TRANSPLANT.pptx
 
revasularisation of acute stroke.pptx
revasularisation of acute stroke.pptxrevasularisation of acute stroke.pptx
revasularisation of acute stroke.pptx
 
CVA BY DR.Manoj.pptx
CVA BY DR.Manoj.pptxCVA BY DR.Manoj.pptx
CVA BY DR.Manoj.pptx
 
Stroke management
Stroke managementStroke management
Stroke management
 
Alcoholic septal ablation
Alcoholic septal ablationAlcoholic septal ablation
Alcoholic septal ablation
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complications
 
SAH for Neurology Residents
SAH for Neurology ResidentsSAH for Neurology Residents
SAH for Neurology Residents
 
STEMI F5.pptx
STEMI F5.pptxSTEMI F5.pptx
STEMI F5.pptx
 
IC TT 01.pptx
IC TT 01.pptxIC TT 01.pptx
IC TT 01.pptx
 
Cardiac Resynchronisation therapy.pptx
Cardiac Resynchronisation therapy.pptxCardiac Resynchronisation therapy.pptx
Cardiac Resynchronisation therapy.pptx
 
DSA complication
DSA complicationDSA complication
DSA complication
 
TIA and stroke prevention
TIA and stroke preventionTIA and stroke prevention
TIA and stroke prevention
 
transient ischemic attacks- advances in diagnosis & mx
transient ischemic attacks- advances in diagnosis & mxtransient ischemic attacks- advances in diagnosis & mx
transient ischemic attacks- advances in diagnosis & mx
 
Acute Coronary syndrome - Pharmacotherapy
Acute Coronary syndrome - PharmacotherapyAcute Coronary syndrome - Pharmacotherapy
Acute Coronary syndrome - Pharmacotherapy
 
Carotid+lecture+final[1].ppt
Carotid+lecture+final[1].pptCarotid+lecture+final[1].ppt
Carotid+lecture+final[1].ppt
 
Anesthesia for Carotid Surgery
Anesthesia for Carotid SurgeryAnesthesia for Carotid Surgery
Anesthesia for Carotid Surgery
 
How should recently symptomatic patients be treated urgent cea or cas
How should recently symptomatic patients be treated urgent cea or casHow should recently symptomatic patients be treated urgent cea or cas
How should recently symptomatic patients be treated urgent cea or cas
 

Mehr von Wahid altaf Sheeba hakak

Anaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesAnaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesWahid altaf Sheeba hakak
 
Anaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesAnaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesWahid altaf Sheeba hakak
 
pleural procedures and thoracic ultrasound BTS 2010 guidelines
pleural procedures and thoracic ultrasound BTS 2010 guidelinespleural procedures and thoracic ultrasound BTS 2010 guidelines
pleural procedures and thoracic ultrasound BTS 2010 guidelinesWahid altaf Sheeba hakak
 

Mehr von Wahid altaf Sheeba hakak (20)

Rhabdomyolysis
RhabdomyolysisRhabdomyolysis
Rhabdomyolysis
 
Pediatric burns
Pediatric burnsPediatric burns
Pediatric burns
 
Acute liver failure in icu
Acute liver failure in icuAcute liver failure in icu
Acute liver failure in icu
 
Anaesthesia for wrong site surgery
Anaesthesia for wrong site surgeryAnaesthesia for wrong site surgery
Anaesthesia for wrong site surgery
 
Cystic fibrosis anaesthesia presentation
Cystic fibrosis anaesthesia presentation Cystic fibrosis anaesthesia presentation
Cystic fibrosis anaesthesia presentation
 
Emergency warfarin reversal a
Emergency warfarin reversal aEmergency warfarin reversal a
Emergency warfarin reversal a
 
Predicting difficult intubation
Predicting difficult intubationPredicting difficult intubation
Predicting difficult intubation
 
Anaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesAnaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergencies
 
Anaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergenciesAnaesthetic management of obstetric emergencies
Anaesthetic management of obstetric emergencies
 
Arrhythmias final
Arrhythmias finalArrhythmias final
Arrhythmias final
 
Sickle cell ppt
Sickle cell pptSickle cell ppt
Sickle cell ppt
 
Ponv anaesthesia managment
Ponv anaesthesia managmentPonv anaesthesia managment
Ponv anaesthesia managment
 
Valvular heart disease and anaesthesia
Valvular heart disease and anaesthesiaValvular heart disease and anaesthesia
Valvular heart disease and anaesthesia
 
Spina bifida and epidural anaesthesia
Spina bifida  and epidural anaesthesiaSpina bifida  and epidural anaesthesia
Spina bifida and epidural anaesthesia
 
Cosyntrophin for pdph
Cosyntrophin for pdphCosyntrophin for pdph
Cosyntrophin for pdph
 
Ards goals
Ards goalsArds goals
Ards goals
 
Fascia iliaca block for neonates
Fascia iliaca block for neonates Fascia iliaca block for neonates
Fascia iliaca block for neonates
 
Pacemaker and anaesthesia
Pacemaker and anaesthesiaPacemaker and anaesthesia
Pacemaker and anaesthesia
 
Fascia iliaca block in neonates
Fascia iliaca block in neonatesFascia iliaca block in neonates
Fascia iliaca block in neonates
 
pleural procedures and thoracic ultrasound BTS 2010 guidelines
pleural procedures and thoracic ultrasound BTS 2010 guidelinespleural procedures and thoracic ultrasound BTS 2010 guidelines
pleural procedures and thoracic ultrasound BTS 2010 guidelines
 

Último

SGK PHÙ PHỔI CẤP ĐHYHN .pdf
SGK PHÙ PHỔI CẤP ĐHYHN                   .pdfSGK PHÙ PHỔI CẤP ĐHYHN                   .pdf
SGK PHÙ PHỔI CẤP ĐHYHN .pdfHongBiThi1
 
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...DUY NGUYEN PHUC
 
Reproductive and Child Health Services ppt.pptx
Reproductive and Child Health Services ppt.pptxReproductive and Child Health Services ppt.pptx
Reproductive and Child Health Services ppt.pptxVeereshDemashetti
 
Thyroid function tests for MBBS, LAB. MED & BDS.pptx
Thyroid function tests for MBBS, LAB. MED & BDS.pptxThyroid function tests for MBBS, LAB. MED & BDS.pptx
Thyroid function tests for MBBS, LAB. MED & BDS.pptxRajendra Dev Bhatt
 
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdf
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdfSGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdf
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdfHongBiThi1
 
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxsiddharthroy26587
 
SGK VIÊM KHỚP DẠNG THẤP YHN .pdf
SGK VIÊM KHỚP DẠNG THẤP YHN              .pdfSGK VIÊM KHỚP DẠNG THẤP YHN              .pdf
SGK VIÊM KHỚP DẠNG THẤP YHN .pdfHongBiThi1
 
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptxCholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptxRajendra Dev Bhatt
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedSBL DIGITAL
 
TARGET DELINEATION IN VULVAL CANCER BY DR KANHU
TARGET DELINEATION IN VULVAL CANCER BY DR KANHUTARGET DELINEATION IN VULVAL CANCER BY DR KANHU
TARGET DELINEATION IN VULVAL CANCER BY DR KANHUKanhu Charan
 
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeTracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeQuick MedTalk
 
(IDE)and(IVD),QMS,21 CFR part820 , 801)
(IDE)and(IVD),QMS,21 CFR part820  , 801)(IDE)and(IVD),QMS,21 CFR part820  , 801)
(IDE)and(IVD),QMS,21 CFR part820 , 801)chahattyagi200
 
Spinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxSpinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxsiddharthroy26587
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisAshishMaletha2
 
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedDerma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedSBL DIGITAL
 
Human Skeletal System_By Anupam Das......
Human Skeletal System_By Anupam Das......Human Skeletal System_By Anupam Das......
Human Skeletal System_By Anupam Das......anupamdas2143
 
bleeding disorders 1 Dr.Nannika Pradhan
bleeding disorders 1  Dr.Nannika Pradhanbleeding disorders 1  Dr.Nannika Pradhan
bleeding disorders 1 Dr.Nannika Pradhanthesalberry
 
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptx
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptxANATOMY OF CEREBELLUM With Clinical Anatomy.pptx
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptxsiddharthroy26587
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...JakeMatthews12
 
INTRODUCTION TO THE FORENSIC SCIENCE.ppt
INTRODUCTION TO THE FORENSIC SCIENCE.pptINTRODUCTION TO THE FORENSIC SCIENCE.ppt
INTRODUCTION TO THE FORENSIC SCIENCE.pptKavitha Krishnan
 

Último (20)

SGK PHÙ PHỔI CẤP ĐHYHN .pdf
SGK PHÙ PHỔI CẤP ĐHYHN                   .pdfSGK PHÙ PHỔI CẤP ĐHYHN                   .pdf
SGK PHÙ PHỔI CẤP ĐHYHN .pdf
 
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
 
Reproductive and Child Health Services ppt.pptx
Reproductive and Child Health Services ppt.pptxReproductive and Child Health Services ppt.pptx
Reproductive and Child Health Services ppt.pptx
 
Thyroid function tests for MBBS, LAB. MED & BDS.pptx
Thyroid function tests for MBBS, LAB. MED & BDS.pptxThyroid function tests for MBBS, LAB. MED & BDS.pptx
Thyroid function tests for MBBS, LAB. MED & BDS.pptx
 
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdf
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdfSGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdf
SGK BỆNH LÝ GOUT YHN hay lắm nha aaaa.pdf
 
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
 
SGK VIÊM KHỚP DẠNG THẤP YHN .pdf
SGK VIÊM KHỚP DẠNG THẤP YHN              .pdfSGK VIÊM KHỚP DẠNG THẤP YHN              .pdf
SGK VIÊM KHỚP DẠNG THẤP YHN .pdf
 
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptxCholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limited
 
TARGET DELINEATION IN VULVAL CANCER BY DR KANHU
TARGET DELINEATION IN VULVAL CANCER BY DR KANHUTARGET DELINEATION IN VULVAL CANCER BY DR KANHU
TARGET DELINEATION IN VULVAL CANCER BY DR KANHU
 
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeTracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
 
(IDE)and(IVD),QMS,21 CFR part820 , 801)
(IDE)and(IVD),QMS,21 CFR part820  , 801)(IDE)and(IVD),QMS,21 CFR part820  , 801)
(IDE)and(IVD),QMS,21 CFR part820 , 801)
 
Spinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxSpinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptx
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth Analysis
 
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedDerma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
 
Human Skeletal System_By Anupam Das......
Human Skeletal System_By Anupam Das......Human Skeletal System_By Anupam Das......
Human Skeletal System_By Anupam Das......
 
bleeding disorders 1 Dr.Nannika Pradhan
bleeding disorders 1  Dr.Nannika Pradhanbleeding disorders 1  Dr.Nannika Pradhan
bleeding disorders 1 Dr.Nannika Pradhan
 
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptx
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptxANATOMY OF CEREBELLUM With Clinical Anatomy.pptx
ANATOMY OF CEREBELLUM With Clinical Anatomy.pptx
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...
 
INTRODUCTION TO THE FORENSIC SCIENCE.ppt
INTRODUCTION TO THE FORENSIC SCIENCE.pptINTRODUCTION TO THE FORENSIC SCIENCE.ppt
INTRODUCTION TO THE FORENSIC SCIENCE.ppt
 

Thrombectomy for ischemic stroke and anaesthesia

  • 1. Audit/Research projects July-December 2013. Dr Wahid Altaf Dr Sinead Galvin
  • 2. Stroke • Sudden death of cells due to lack of oxygen. • Manifesting as focal or global disturbance of cerebral function lasting for more than twenty four hours or leading to death. • Survival of brain cells depends on time since lack of oxygen.
  • 4. Stroke in Ireland • Annual number of stroke patients in Ireland is around 10,000.87% ischemic stroke. • Annual number of deaths from stroke is 2000. • Number of disabled patients secondary to stroke around 30,000.
  • 5. Risk factors for Ischemic stroke • • • • Non-Modifiable Age Male sex Race Inheritance • • • • • • • Modifiable Hypertension Daibetes Mellitus Cardiac disease (AF) Cigarette smoking Obesity Increase homocysteine Inc Cholesterol.
  • 6. Diagnosis and treatment • Its early diagnosis is important as its treatment is dependent on the time elapsed since the onset of the symptoms. Delay in diagnosis and treatment translates into increased neuronal loss and thereby increased morbidity. • Reperfusion remains the mainstay of acute ischemic stroke treatment .
  • 7. Time is Brain!!!! • The average duration of non-lacunar stroke evolution is 10 hours (range 6 to 18 hours), and the average number of neurons in the human forebrain is 22 billion. • In each minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. • Compared with the normal rate of neuron loss in brain aging, the ischemic brain ages 3.6 years each hour without treatment.
  • 9. Treatment options available. • IV rtPA therapy. • Mechanical clot disruption with IAT. • Thrombectomy.
  • 11. Mechanical thrombectomy • Recanalization by mechanical thrombectomy may occur due to combination of thrombus fragmentation, thrombus retrieval, and enhancement of fibrinolytic penetration. • FDA cleared many devices for recanalization of arterial occlusion in patients with ischemic stroke.
  • 12. The Evidence ???? • NINDS iv tpa <3hours. • ECASS III iv alteplase 3-4.5 hours. • PROACT II ia pro uk <6hours. • MERCI thrombectomy, 8hours.
  • 21. General anesthesia for Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy in Beaumont Hospital
  • 22. Background • Avoid anesthesia Speed of whole process Avoid anesthetic drug effectshypotension or effect on cerebral activity • Need for anesthesia can’t be ignored. • Retrospective review on type and number of patients who got general anesthesia during last three years for clot retrieval in radio-intervention suite of Beaumont hospital. • Identify demand, issues and future.
  • 23. Clot retrieval in Beaumont Hospital from April 2010 to Sept 2013. • Total number of cases done 107.
  • 28. Demographics of patients for GA Male 5 Female 7 Age years (Average) 32-73(55)
  • 29. Overall Risk factors Risk factor Number of patients High blood pressure 40 High cholesterol 18 Previous CVA 11 Ischemic heart disease 12 Atrial Fibrillation 26 Diabetes Mellitus 6 Smoking 20
  • 30. Risk factors in GA patients Risk factor Number of patients Hypertension 6 Ischemic heart disease 2 Atrial fibrillation 2 Smoking 1 Dyslipidemia 3
  • 31. Stroke scale of patients (NIHSS)
  • 32. NIHSS at presentation of all patients.
  • 33. NIHSS at presentation of GA patients
  • 34. Stroke characteristicsVessel involved Stroke characteristics Number of patients Right sided 51 Left sided 56 Middle cerebral artery M1 59 Middle cerebral artery M2 13 Internal carotid artery 35 Basilar artery 5 Multiple vessels 42
  • 35. Stroke characteristic of GA patients Vessel Involved Stroke characteristics Number of patients Right 8 Left 4 Internal carotid artery 6 Middle cerebral artery M1 6 Vertebral artery 1 Basilar artery 1
  • 37. IV Thrombolysis pre procedure
  • 39. Hemodynamic parameters in GA patients during the procedure Parameter Values Range (Average) mmHg Systolic BP 100-140 (120) Diastolic BP 60-90 (65) Mean BP 73-106 (83)
  • 40. Vasopressors used to maintain blood pressure in GA patients
  • 41. Complications Complication Number of patients Procedural complications 15 Haemorrhage 28 Clinically significant haemorrhage 12
  • 42. ICU Admission post procedure of GA patients
  • 43. MRS at 3 months.
  • 44. MRS of GA patients
  • 46. Prognosis of GA patients
  • 47. Prognosis with intra-op Blood pressure Mean Arterial BP (mmHg) Survived Dead Unknown < or= 80 1 4 1 >80 5 1 0
  • 48. Issues important to us. • • • • Increasing demand over the years. Out of hours service needed. High ASA grade of these patients. Failed IV thrombolysis before clot retrieval and consequences thereof. • Internal carotid and middle cerebral artery involvement in majority. • Hemodynamic parameters to target/Blood glucose control and means to achieve the same/maintaining normothermia. • Need for ICU/Ventilation post procedure.
  • 49. Future • Our demand to provide anesthesia for sick patients may increase with time. • Develop standard procedures and protocols. • Canadian multi-centric trial for outcome from clot retrieval. • Clot retrieval in interventional cardiology.
  • 50. Quality improvement maneuver • Safer and standard anesthetic practice Standard monitoring as per AAGBI. IV canula with IV fluids running via 3 way tap. Anesthetic machine checked every day and ready in high risk patients. Emergency drugs/Airway tray ready to use.

Hinweis der Redaktion

  1. However &gt; 50% do not demonstrate a favourable outcome
  2. National Institute of Neurological Disorders and Stroke (NINDS) 1995 European Cooperative Acute Stroke Study III (ECASS III) 2008 The Prolyse in Acute Cerebral Thromboembolism (PROACT) trial 1998 Mechanical embolus removal in cerebral ischemia. 2008
  3. BACKGROUNDThrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke.Full Text of Background...METHODSThe trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS.Full Text of Methods...RESULTSIn part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P&lt;0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30).
  4. BACKGROUNDIntravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke.Full Text of Background...METHODSAfter exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events.Full Text of Methods...RESULTSWe enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P&lt;0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P=0.008). Mortality did not differ significantly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference in the rate of other serious adverse events
  5. Background and Purpose—To test the safety and recanalization efficacy of intra-arterial local delivery of plasminogen activators in acute ischemic stroke, a randomized trial of recombinant pro-urokinase (rpro-UK) versus placebo was undertaken in patients with angiographically documented proximal middle cerebral artery occlusion.Methods—After exclusion of intracranial hemorrhage by CT scan, patients with abrupt onset of symptoms of focal ischemia likely to receive treatment within 6 hours who satisfied all clinical eligibility criteria underwent carotid angiography. Patients displaying Thrombolysis in Acute Myocardial Infarction grade 0 or 1 occlusion of the M1 or M2 middle cerebral artery were randomized 2:1 to receive rpro-UK (6 mg) or placebo over 120 minutes into the proximal thrombus face. All patients received intravenous heparin. Recanalization efficacy was assessed at the end of the 2-hour infusion, and intracerebral hemorrhage causing neurological deterioration was assessed at 24 hours.Results—Of 105 patients who underwent angiography, 59 were excluded from randomization. Among the 46 patients randomized, 40 were treated with rpro-UK (n=26) or placebo (n=14) a median of 5.5 hours from symptom onset. Recanalization was significantly associated with rpro-UK (2P=.017). Hemorrhagic transformation causing neurological deterioration within 24 hours of treatment occurred in 15.4% of the rpro-UK–treated patients and 7.1% of the placebo-treated patients (2P=.64). Both recanalization and hemorrhage frequencies were influenced by heparin dose.
  6. Merci Mechanical embolus removal in cerebral ischemia Background and Purpose— Endovascular mechanical thrombectomy may be used during acute ischemic stroke due to large vessel intracranial occlusion. First-generation MERCI devices achieved recanalization rates of 48% and, when coupled with intraarterial thrombolytic drugs, recanalization rates of 60% have been reported. Enhancements in embolectomy device design may improve recanalization rates.Methods— Multi MERCI was an international, multicenter, prospective, single-arm trial of thrombectomy in patients with large vessel stroke treated within 8 hours of symptom onset. Patients with persistent large vessel occlusion after IV tissue plasminogen activator treatment were included. Once the newer generation (L5 Retriever) device became available, investigators were instructed to use the L5 Retriever to open vessels and could subsequently use older generation devices and/or intraarterial tissue plasminogen activator. Primary outcome was recanalization of the target vessel.Results— One hundred sixty-four patients received thrombectomy and 131 were initially treated with the L5 Retriever. Mean age±SD was 68±16 years, and baseline median (interquartile range) National Institutes of Health Stroke Scale score was 19 (15 to 23). Treatment with the L5 Retriever resulted in successful recanalization in 75 of 131 (57.3%) treatable vessels and in 91 of 131 (69.5%) after adjunctive therapy (intraarterial tissue plasminogen activator, mechanical). Overall, favorable clinical outcomes (modified Rankin Scale 0 to 2) occurred in 36% and mortality was 34%; both outcomes were significantly related to vascular recanalization. Symptomatic intracerebral hemorrhage occurred in 16 patients (9.8%); 4 (2.4%) of these were parenchymal hematoma type II. Clinically significant procedural complications occurred in 9 (5.5%) patients.
  7. Background: Studies of endovascular treatment for acute ischemic stroke have identified general anesthesia as a predictor for poor outcome in comparison with local anesthesia/ sedation. This retrospective study attempts to identify modifiable factors associated with poor outcome, while adjusting for baseline stroke severity, in patients receiving general anesthesia. Methods: We reviewed charts of 129 patients treated between January 2003 and September 2009. The primary outcome was the modified Rankin Score of 0–2 for 3 months poststroke. Predictors of neurologic outcome included baseline National Institutes of Health Stroke Scale score, blood glucose concentration, and age. Additional risk factors evaluated were prolonged stroke onset-treatment interval and systolic blood pressure less than 140 mmHg. Choice of local anesthesia or general anesthesia was recorded. Results: The study group was 96 out of 129 patients for whom modified Rankin Scale scores were available; 48 patients received general anesthesia and 48 local anesthesia. The proportion of patients with “good” outcomes were 15% and 60% in the general anesthesia group and local anesthesia group, respectively (P 0.001). Lowest systolic blood pressure and general anesthesia were correlated (r0.7, P 0.001). Independent predictors for good neurologic outcome were local anesthesia, systolic blood pressure greater than 140 mmHg, and low baseline stroke scores. Conclusions: Adjusted for stroke severity, patients who received general anesthesia for treatment are less likely to have a good outcome than those managed with local anesthesia. This may be due to preintervention risk not included in the stroke severity measures. Hypotension, more frequent in the general anesthesia patients, may also contribute
  8. Background and Purpose—Baseline hyperglycemia has been considered an independent predictor of stroke outcome. The present study analyzes the dynamics of serum glucose levels within the first 24 hours and its impact on stroke outcome. Methods—We studied 748 patients with acute ischemic hemispheric stroke in the second European Cooperative Acute Stroke Study (ECASS-II). The patients had 2 serum glucose measurements, at baseline and at 24 hours. Four dynamic patterns were defined as baseline hyperglycemia present only at baseline, 24-hour hyperglycemia present only at 24 hours, persistent hyperglycemia, ie, hyperglycemia at baseline and at 24 hours, and persistent normoglycemia, ie, normoglycemia at baseline and at 24 hours. The end points were 7-day neurological improvement on National Institutes of Health Stroke Scale, 30-day favorable functional outcome (Barthel Index 95 or 100), 90-day negligible dependence (modified Rankin Scale 0 to 2), all-cause mortality within 90 days, and hemorrhagic transformation on CT within the first 7 days. Results—In nondiabetic patients, persistent hyperglycemia was inversely associated with neurological improvement (OR0.31; 95% CI0.16 to 0.60), 30-day favorable functional outcome (OR0.27; 95% CI0.12 to 0.62), and 90-day negligible dependence (OR0.36; 95% CI0.17 to 0.73); it was associated with an increased risk of mortality within 90 days (OR7.61; 95% CI3.23 to 17.90) and for parenchymal hemorrhage (OR6.64; 95% CI2.63 to 16.78), whereas it was inversely associated with hemorrhagic infarction (OR0.30; 95% CI0.13 to 0.71). Delayed hyperglycemia at 24 hours was associated with the risks of death (OR5.99; 95% CI2.51 to 14.2) and parenchymal hemorrhage (OR5.69; 95% CI-2.05 to 15.8) and inversely associated with no and negligible dependency (OR0.40; 95% CI0.20 to 0.78). Hyperglycemia at baseline only was not associated with any parameter of worse outcome. In patients with diabetes, the dynamic patterns of hyperglycemia did not suggest an association with stroke outcome. Conclusions—Persistent hyperglycemia was associated with all bad outcome end points studied. In addition to a single glucose measurement, the pattern of change should be considered in the prediction of stroke outcome. ( Stroke. 2008; 39:2749-2755.)