Interventions in Stroke-Evidence based management

1Copyright © 2015 Dr. Vipul Gupta . All rights reserved. 1
Head, Neurointerventional Surgery &
Interventional Neuroradiology
NEUROVASCULAR & STROKE CENTRE,
Medanta-The Medicity
Dr Vipul
Gupta
Interventions in stroke:Interventions in stroke:
Evidence based managementEvidence based management

2Copyright © 2015 Dr. Vipul Gupta . All rights reserved.
Neurovascular diseases…Stroke….
 Third most common cause of death
 Most common reason for disability
 Appx. 1 in 4 people die within 1 year
 30%–50% do not regain functional
independence
 Annual incidence rate of stroke in India
currently is 145 per 100,000 population
 10 - 15% occur in < 40 years
WHO estimates suggest that by 2050, 80% stroke
cases in the world would occur in low and middle
income countries mainly India and China

Endovascular neurointerventions !!!
 Disease states different
 End- organ different- every area
important
 Reactive organ- reperfusion-
bleed
 Arteries different
 Access difficult- tortuosity

Neurointerventions…
 SAH- aneurysms, vasospasm
 Intracerebral hemorrhage- AVMs
 TIA- major vessel stenosis E/C & I/C
 Stroke- revascularization
 Diagnosis- Imaging
 Interventional hardware
 Integrated approach

ISCHAEMIC stroke- brain attack
Penumbra
• At 60 min, about 90%
• At 2 h about 80 %
• At 3 h about 60% and
• At 4.5 h about 40% of patients
 Thereafter ?
• Maybe 30% at 9 h
• And less than 20% beyond 12 h

Penumbra and Treatment Options
0
10
20
30
min
CBF(ml/100g/min)
300 9060 4120 5 6 24 48h
Infarct-
threshold
Penumbra
Normal Vital tissue
InfarctSingle cell
necrosis
3

IV tPA- indications
ASA/AHA guidelines
Stroke - 2013
Less than 10% patients are eligible

Issues with IV tPA
 Time factor
 Large vessel disease
 Time to recanalize
 C.I. – anti-coagulants, recent surgery, wake-up strokes….
 < 5 % qualify

CT, CTA, CTP….
CT perfusion imaging
MTTCBF CBV
CBV – 2ml/gm- infarcted core;
CBF, MTT - hyoperfusion area

Concept of Penumbra
CBF/MTT CBV
Matched
No penumbra
CBF/MTT
CBV
penumbra
CTA & CTP vs MR DWI & PWI

Imaging approaches for case selection
 NCCT (ASPECTS)- NIHSS
 NCCT & CTA, CTA-SI
 NCCT, CTA & CTP
 MRI-DWI, (MRA, PWI)
What information is needed?
• Bleed
• Infarct core – is critical 70-100 ml
• Major vessel occlusion
• Tissue at risk- penumbra
Time, imaging interpretation, unstable patients

Evidence – 2014-2015
 IMS-III, MR RESCUE & Synthes – failed- no appropriate imaging and old devices
 Recent trials – imaging for MVO & stent- retreviers
 MR CLEAN – strongly positive
 ESCAPE – stopped bcs of efficacy
 EXTEND –IA – positive
DRAMATIC CHANGE IN MGT OF STROKE

MR CLEAN
(Netherlands)
ESCAPE
(CANADIAN)
EXTEND IA
(AUSTRALIAN)
SWIFT PRIME
(USA)
REVASCAT
(SPANISH)

Comparison of protocol- Randomised (Intervention
Vs Standard medical therapy)
• Documented MVO.- ICA, MCA (M1, M2)
• Time based: 6 hrs (initiation of IA therapy)-
(8 hrs – REVASCAT; 12 hrs – ESCAPE)
• Small Core - CT ASPECTS ≥ 6
• CTP – EXTEND IA; SWIFT PRIME
• Predominantly stent retrievers.
• 86.1 to 100% (100 % in EXTEND IA & SWIFT PRIME)
• (NIHSS scores were 17 (interquartile range, 13–21)

TICI 2B/3 – 59% - 88% - (previous trials 25%, 41%)
Recanalization – TICI 2B/3

Absolute Benefit (good outcome) : 13.5% to 31.4%
(Statistically significant)
mRS (90 d)

no significant difference
sICH

Absolute mortality benefit : 8.6%
(Statistically significant in ESCAPE)
Mortality

Comparison of NNT:
EVT: NNT (benefit) - 3.1 to 4.2 (excluding MR CLEAN)
IV tPA ( 3 – 4.5 hours) – 13.8 (ECASS – 3)
Primary PCI (prevent re-infarction) – 33

Clinical … Left hemiplegia, left UL and LL 0/5
 5:14AM

6:22AM

8:07 AM
Patient made gradual recovery
Left LL 4/5 and UL 3/5 - 30 day follow up
mRS at 90 days- 0

 63 /M, AVR, Coumadin
 INR of 2.5
 RT hemiparesis - 2/5 in leg
and 0/5 in arm
 Global aphasia
CBF CBV
Solitaire stent was deployed

Patient presented with in 2 hours
Futile IV tpa

AHA/ ASA guideline 2015:
Patients should receive endovascular therapy with a stent
retriever if they meet all the following criteria (Class I; Level of
Evidence A). (New recommendation):
 prestroke mRS score 0 to 1
 acute ischemic stroke receiving intravenous r-tPA within 4.5
hours of onset
 causative occlusion of the internal carotid artery or proximal
MCA (M1)
 age ≥18 years
 NIHSS score of ≥6
 ASPECTS of ≥ 6
 treatment can be initiated (groin puncture) within 6 hours of
symptom onset

AHA/ ASA guideline:
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 (Class IIa; Level of Evidence C).
Carefully selected patients with acute ischemic stroke in
whom treatment can be initiated (groin puncture) within 6
hours of symptom onset and who have causative occlusion of
the M2 or M3 portion of the MCAs, anterior cerebral arteries,
vertebral arteries, basilar artery, or posterior cerebral arteries
(Class IIb; Level of Evidence C)
Waiting after IV tPA not required (Class III)

Beyond 6 hours – Should you consider
MT?
ESCAPE: up to 12-hours – positive trial
6 hours
49 patients
rate ratio, 1.7; (95% CI, 0.7 to 4.0)
Not significant; however few numbers.
REVASCAT: upto 12 hours, positive trial
Data not provided.

•
60 years old female.Acute onset left hemiparesis and left
facial weakness; CT Brain , CTP and CTA done 6 1/2 hours
after ictus.

Our results
 Total No. of patients= 42 (M-19, F- 23)
 Time of arrival: 30 min- 840 min (mean 203.8 minutes)
 NIHSS at admission: 5-22 (Mean 14.33)
 MVO 39, IV tPA- 19
Good recanalization (TICI 2b or 3) in 57.1%
mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)
Recanalization V/s Outcome

ANEURYSMS- basic facts
• Subarachnoid hemorrhage (SAH).
• One in every 20 strokes , at the
prime of ones life (commonly
between 40-50yrs).
• Up to 40-50% patients do not
survive even for a month mostly
because of the rerupture of the
aneurysm
• With proper treatment up to 90% of
patient who reach hospital before
any major damage has happened will
lead an independent and productive
life
Initial CT Scan
Rebleeding after 1 day

Clipping vs coiling…
Initially
 Surgically inappropriate
Tremendous changes in last 15-yrs
Cerebral Aneurysms-
• Image-guidance (3-D , Dyna-CT)
• Coil, catheter, balloons, stents
• Drugs- aspirin, clopidogrel, abciximab
• Appx. 90% by endovascular
• Intra-arterial vasospasm mgt.
• HELP and Cerecyte studies – mRS 0-2 in
87% (80% in ISAT)

ISAT
 Randomized, prospective,
international trial
 Clipping vs coiling
 ISAT follow-up, Lancet 2014- at 9 yrs,
outcome better
 Guidelines for the Management of Aneurysmal SAH: Special
Writing Group of the Stroke Council, ASA/AHA Stroke 2009
 Amenable to both endovascular coiling and neurosurgical
clipping, endovascular coiling can be beneficial (Class I, Level
of Evidence B).
Metanalysis- Stroke 2013, AJNR 2013
• Ruptured aneurysms- better outcomes
after endovascular management

Broad neck aneurysmBroad neck aneurysm

Dissecting
blister
aneurysm –
poor grade
EVD
2-overlapping Enterprise stents
6-months
follow-up
Blister/
dissecting
aneurysms

Flow diverters (stents)-
no coils

Vasospasm- 15-25% morbidity and mortality

Day 7
Continuous intra-arterial dilatation
Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.
Anand S, Goel G, Gupta V.
J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]

Our protocol
 Interventionist part of
neurosurgery team
 DSA & if possible embolization
 Neuro lab with 3D, CT
 NS ICU monitoring (TCD/CTP).
 Vasospasm- IAVD
 N- 706 (Sept 2014)
 Data of consecutive patients

Our protocol
 Interventionist part of
neurosurgery team
 DSA & if possible
embolization
 Neuro labwith 3D, CT
 NS ICU monitoring
(TCD/CTP).
 Vasospasm- IAVD
 N- 540 (Jan 2014)
Embolization
Surgery
91%
9%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-
2

CAROTID ARTERY STENOSIS-
20-25% STROKES BY MAJOR VESSEL
STENOSIS

Symptomatic StenosisSymptomatic Stenosis
• Non-invasive >70%Non-invasive >70%
• Catheter angiography >50%Catheter angiography >50%
• Peri-procedural risk <6%Peri-procedural risk <6%
Asymptomatic StenosisAsymptomatic Stenosis
• >70% Stenosis>70% Stenosis
• Periprocedural complication risk is lowPeriprocedural complication risk is low
• Life expectancy >5 yrLife expectancy >5 yr
• >80% stenosis- tend to be treated>80% stenosis- tend to be treated
Revascularization indications-Revascularization indications-
ASA/AHA guidelines 2011ASA/AHA guidelines 2011

STENTING FOR SEVERE CAROTID STENOSIS

Patient with TIAs…..stenting done the next day
Should be done as soon as possible…
maximum stroke risk in first few weeks

CAS vs CEA- CREST – NEJM 2011
•2502 patients- Outcome largely same
•More MI in surgery ; more minor strokes in CAS
•Stenting better in 70yrs and less age group
•Nerve palsies not included in end-points
•Less than 1% major stroke
ASA/AHA guidelines 2014-
Endarterectomy and stenting are alternatives (Class I evidence)
<70 yrs, stenting may be preferable

• Microemboli
• Plaque morphology
• Vasomotor reactivity
• Silent infarcts
• Progression

Transient ischaemic attack
• Meta-analysis of 11 observational studies:
Risk of stroke at 2, 30 and 90 days after TIA was 9.9,
13.4 and 17.3% respectively
• Pooled analysis of 3206 pts with TIA and DWI
imaging, risk of stroke at 7 days was much lower in
those without infarction compared to those with
infarction: 0.4% vs 7.1%
Coull et
al. BMJ
2004
Minor
Cerebrovascular
Syndrome

 ABCD3
 ABCD3 – I score
 Multicenter pooled analysis:
UK + Ireland for Derivation
model
 Oxfordshire (UK) + California
(US) for Validation model

TIAs/minor stroke
 High risk of stroke in first few weeks
 Patients with DWI lesions and arterial stenosis have
higher risk
 Revascularization should be done soon

CT Delayed …..

Intracranial atherosclerosis
 Intracranial arterial stenosis is responsible for 6%
to 10% of ischemic strokes in whites and 22% to
26% of ischemic strokes in Asians
SAMPRIS Trial- stenting not to be
done as routine in acute stroke
•Recurrent symptom
•Subocclusive stenosis

Clinical-
 Bleeding
 Seizures
 Neurological deficit
 Headaches
 Incidental
Cerebral ArteriovenousCerebral Arteriovenous
malformationsmalformations

AVM- treatment options
 Embolization
 Radiosurgery (Gamma Knife, LINAC, Cyberknife)
 Surgery
Embolization
Glue (NBCA) vs Onyx embolization

Conclusion
 Advances in Neuroimaging and
neurointervention
 Critical role in mgt of SAH-
aneurysm, Acute stroke, TIA-
carotid stenosis, ICH-AVMs
 Latest trials have proven the role
in acute stroke
 Neurointerventionist, neurologist,
neurosurgeon and radiologist as a
team

Exciting time in neurosciences …
 Interventional treatment methods for diseases like epilepsy, parkinsonism,
headaches …..
 Image guidance in neurosurgery
 Radiosurgery – Gamma Knife , Cyberknife
 Minimally invasive spine and brainsurgery
 Rapid evolution in approach
 Multidisciplinary , team approach

For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
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Dr Vipul Gupta

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Interventions in Stroke-Evidence based management

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