Konon, plenary pertama International Stroke Conference (ISC) 2015 yang digelar di Nashville, Tennessee bulan Februari lalu merupakan sesi ISC terseru selama beberapa tahun terakhir. Sebagaimana diberitakan dalam Medscape (Hughes, 2015), para presenter terpaksa memberi jeda beberapa saat untuk menyambut applause dari audiens. Suatu kejadian langka dalam partemuan saintifik. Adalah MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME yang menjadi topik hangat lantaran keempat studi ini dirilis dengan hasil yang positif dramatis hingga diprediksi bakal menjadikan terapi endovascular sebagai standar baru dalam manajemen stroke iskemik akut. Sehebat apakah 4 studi yang “menyejarah” dalam tatalaksana stroke iskemik akut ini? Bagaimana bila studi-studi ini diadopsi dan diaplikasikan dalam praktik sehari-hari di sentra kita? Note: Esai ini ditulis saat SWIFT PRIME fulltext belum published (akhir Maret-awal April 2015). Update & beberapa revisi dibuat menjelang presentasi tanggal 18 Mei 2015.

1. Terapi Endovaskuler
Standar Baru Manajemen Stroke Iskemik Akut?
Tinjauan Hasil Studi MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME
Ersifa Fatimah, dr.
Achmad Firdaus Sani, dr.,SpS,FINS
FK Universitas Airlangga – RS Dr Soetomo
Surabaya | 2015

2. Heart Disease and
Stroke Statistics
2015 Update
• Incidence: stable
• Mortality: decline
• Prevalence: increase
Evaluating the importance of time: the effect of rtPA thrombolysis on
patient outcome by the end of follow-up. Data were taken from two
previously published meta-analyses (ATLANTIS, ECASS and NINDS
Investigators, 2004; Wardlaw et al., 2012). (Balami et al., 2013)
Limitations of iv rtPA
― Narrow time window available for treatment
― The risk of symptomatic intracerebral hemorrhage
― Contraindications
Prevention of stroke-related
disability instead of mortality
2

3. Evolution of endovascular techniques for acute ischemic stroke and clinical trials.
(Pierot et al., 2015)
IA Thrombolysis Mechanical Thrombectomy
3

4. Illustration depicting the major steps in evolution of thrombectomy devices, beginning from the first-generation concept to
state-of-the-art approaches (Spiotta et al., 2015) 4

5. Spiotta et al., 2015
5

6. Key Factors
Fargen et al., 2015
Timing endovascular therapy
Target: selected patient with blocked artery
Technology / device: new generation
6

7. 7

8. 8

9. Study Design
9
N Engl J Med
April 17, 2015

10. Study Population
10

11. Control Group
Intervention Group
11

12. 12
GA 37%

13. Study Outcome
13

14. Safety
14

15. Kim & Kim, 2014
•Susceptibility to intracranial
atherosclerosis
•High prevalence of ICH, effects of
dietary & lifestyle, and several
disorders with genetic causes.
•Affect acute stroke care
Unique features of stroke in Asia
•Can cause recanalization failure
•Require additional angioplasty /
permanent stent insertion although
intracranial stenting is not an
established strategy
High prevalence of
intracranial atherosclerosis
15
Asians should collaborate to perform their own thrombolytic and
endovascular trials and seek the optimal strategy for stroke care
specific to Asia.
Toyoda et al, 2015
Cervical ICA Stenosis/ Occlusion
MR CLEAN 12.9% stented
ESCAPE 12.7
EXTEND IA 0
SWIFT PRIME 0
Large Artery Occlusion
Accessible | Prognosis: poor without revascularization |
Recanalization with iv rtPA: 30%

16. Conclusion
Safe. Technically successful.
Substantially improved final disability level.
Low complication.
16

17. Further studies will be needed
― the benefit in patients with more distal occlusions
― later time windows
― the influence of the type of device that is used
― variability in the endovascular technique
17

18. 18
“Our results suggest that intravenous plus intra-arterial therapy is the treatment of
preference..”
“We used a different technology — the Penumbra aspiration system.. the first trial where
aspiration was used. ..stipulated patients had to have a long clot, defined as 8 mm or more.”
“..it enrolled a broader population and it did not use sophisticated imaging to select
patients.. REVASCAT had ASPECT scores lower than the other trials.. They also delayed
endovascular therapy to make sure patients did not respond to tPA (tissue plasminogen
activator)..
but they still showed an impressive benefit of thrombectomy.”
“..the benefit of the intervention was seen across the whole population included, but that
certain groups had a particularly large effect. ..patients with the clot in the proximal M1
artery, those with target mismatch (higher ratio of ischemic tissue at risk to irreversibly
infarcted brain), patients with longer clots, and those with excellent collateral circulation.”

19. • Screening a lot of patients to define which specific patients require
endovascular therapy
• Favorable results occur when intra-arterial thrombectomy is performed in
an endovascular stroke center by a coordinated multidisciplinary team
that extends from the prehospital stage (concept of triage and transfer)
to the endovascular suite, minimizes time to recanalization, uses stent-
retriever devices, and avoids general anesthesia.(Grotta & Hacke, 2015) (Pierot &
Derdeyn, 2015)
Challenges in stroke management will be:
19
• Consider endovascular therapy in the armamentarium of treatment
options.
• Change imaging practices to evaluate for large vessel occlusion.
• Establish relationships with centers that have neurointerventionalist.
• All neurologists can help to educate patients about stroke symptoms and
signs and the importance of calling 911—for even more reasons, now!
The trial results will affect many community neurologists.
The Latest in Acute Stroke Management--A Conversation| Mark J. Alberts, Werner Hacke, Helmi L. Lutsep, Bret S. Stetka |
Medscape | April 02, 2015

20. End.
DISCUSSION. 20

21. Special Notes
21

22. Pierot & Derdeyn, 2015 22

23. Menon et al, 2015
23
The common theme in the more imaging selective trials has been to
exclude patients with a large area of irreversibly injured ischemic core…
rapid CT-based selection embedded within streamlined clinical
assessment protocols, where imaging is used to exclude patients with
evidence of large ischemic core (low ASPECTS on NCCT, poor collaterals
on mCTA, or evidence of a large ischemic core on CTP) is attractive.

24. Pierot & Derdeyn, 2015 24

25. LIST OF MECHANICAL THROMBECTOMY DEVICES
THAT ARE AVAILABLE IN THE NETHERLANDS
THEIR MODE OF ACTION AND CURRENT STATUS | from MR CLEAN Protocol
26

26. Alberta Stroke Program Early CT Score
27
Srinivasan et al, 2006

27. ESCAPE Supplementary
Multiphase CTA
28

28. CT Perfusion
Hurley et al, 201229

29. Tong et al, 2014
CT Perfusion
30

30. Tong et al, 2014
31

31. ESCAPE 32

32. End.
Thank You.
38