Alex Abou-Chebl, MD, FSVIN Medical Director, …...Powers WJ, et al. 2015 AHA/ASA Focused Update of...
Transcript of Alex Abou-Chebl, MD, FSVIN Medical Director, …...Powers WJ, et al. 2015 AHA/ASA Focused Update of...
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What Cardiologists Need to Know Before Becoming Stroke
Interventionists II: How to Use Modern Neuro-
Interventional Tools and Techniques to Optimize Stroke Outcomes
Alex Abou-Chebl, MD, FSVIN
Medical Director, Stroke
Baptist Health Louisville
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Disclosure Statement of Financial Interest
• Consulting Fees/Honoraria • The Medicines Co.
• Silk Road Medical
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
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Essential Components of
Endovascular Therapy
• Patient Selection
• Appropriate Team Members
• Rapid Triage to Interventional Lab
• Identification of Site of Occlusion
• Stable Access
• Pharmacological Rx Selection
• Equipment Selection
• Respect the Artery
• Know When to Stop
• Post-Op Care
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Patient Selection
• Intracerebral Hemorrhage is the Wolf
Nipping at Your Heels
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Predictors of ICH
• Severity of deficit- NIHSS≥20
• Duration Of Ischemia
• Size of Infarction- necrotic core, ASPECTS<5
• Size of penumbra
• Blood Pressure
• Blood Glucose
• Patient Age
• Pharmacological Milieu
• Collaterals
• Dementia
• Device
• Choice of Anesthesia
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Avoid General Anesthesia in Acute
Ischemic Stroke EVT
• 12 centers N=980: 44% GA
90d poor outcome OR 2.33 (1.63-3.44), p<0.0001
Mortality OR 1.68 (1.23-2.30), p<0.001
• NASA Registry
90d poor outcome aOR 2.4 (1.2-5.1), p=0.01
Mortality aOR 3.3(1.6-7.1), p=0.001
• IMS III
90d good outcome aOR 0.68 (0.52-0.9), p=0.0056
Mortality aOR 2.84 (1.65-4.91) p=0.0002
Abou-Chebl A et al. Conscious sedation versus general anesthesia during endovascular therapy for acute
anterior circulation stroke: Preliminary results from a retrospective multi-center study. Stroke
2010;41(6):1175-9
Abou-Chebl A, et al. North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry: Choice of
Anesthesia and Outcomes. Stroke 2014;45(5):1396-1401
Abou-Chebl A, et al. Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of
IMS III. Stroke 2015;46(8):2142-8
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Identifying Location of Occlusion
• Excellent Angiographic Technique
Multiple Angles- Steep AP and True Lateral
Large field of view imaging entire skull and scalp
Delayed Filming
Cortical Blush
Vessel Cutoff
Early Venous Shunting
Retrograde Filling
Clinical Correlation
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Illustrative Case
Man With Wernicke’s Aphasia
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Stable Access
• Stable Access vs. Time
8F Balloon Guide in proximal ICA or
Subclavian (? VA)
Rarely sheath in common carotid for
extreme proximal tortuosity
Distal access catheters in severe
proximal/distal tortuosity
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Pharmacological Rx Selection
• Heparin
Major risk factor for ICH• PROACT II Trial- 2000U bolus then 500U/hr X4hrs
• Thrombolytics- Limited need- ICH proportional to dose
tPA- 5-20mg
Retevase 2-5U
Urokinase 4-600,000U ?
• GPIIb/IIIa
Post-stenting
IA or IV
¼-1/2 bolus, never an indication for continuous infusion
• NTG
Furlan A, et al. PROACT II. JAMA 1999;282(21):2003-2011
Abou-Chebl A, et al. Multi-modal Therapy for the Treatment of Severe Ischemic Stroke
Combining GPIIb/IIIa Antagonists and Angioplasty after Failure of Thrombolysis. Stroke
2005;36(10):2286-2288
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Equipment Selection
• 6-8F Sheath
• 6F Neuro-guide catheter
• 8F Balloon-guide catheter (7F and 9F available)
Merci™, Cello™
Essential- greatly increases recanalization efficacy
• Hydrophilic 014” soft neurowire
Rarely medium weight to get access
Never stiff wire or CTO wires
Transcend™, Synchro™
• Neuro Microcatheter
Marksman™, Trevo™, Rapid Transit™, etc.
Nguyen T, et al. Balloon guide catheter improves revascularization and clinical
outcomes with Solitaire device: Analysis of NASA Registry. Stroke 2014;45(1):141-145.
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Equipment Selection
• Stent Retriever Device- 1st Line per AHA
Guidelines
Solitaire FR™
• 3x20, 3x30, 4x15, 4x20, 4x30, 6x20, 6x30
Trevo XP Provue™
• 3x20, 4x20, 6x25
• Penumbra Aspiration System™
• Multiple variant techniques
Push and fluff
ADAPT
Solimbra
Powers WJ, et al. 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early
Management of Patients With Acute Ischemic Stroke Regarding Endovascular
Treatment Stroke. 2015;46
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Respect the Artery
• Intracranial Vessel Histology
No external elastic lamina
Minimal adventitia
Thin tunica media/muscularis• ICA above ophthalmic
• VA at foramen magnum
• Subarachnoid course
Near Microscopic perforators• MCA Trunk
• BA Trunk
• BA Apex-PCA
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Respect the Artery
• No touch technique
• Never over-size
• Softest equipment possible
• Know your variants
Fetal PCA ~20%
Circle of Willis complete in 25%
Anterior temporal
Early MCA bifurcation/trifurcation
BA cerebellar branches
Basilar tip configuration
Trigeminal Artery
• Guide position
• “Better is the enemy of good”
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When Do You Stop?
Illustrative Case
• 78yo WM with HTN, Hyperlipidemia, Cigs
• Developed mild aphasia and right
hemiparesis
• Hospitalized
• MRI shows multiple small infarcts
• Tx w Aspirin pending W/U
• 3rd Hosp Day develops complete LICA
syndrome
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LCCA Angiogram
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Post-Stenting Angiogram
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Reopro 20mg Given IA
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When To Stop
• Over 1 hour- ?
Over 2 hours- definitely
• >2 devices or approaches
• Clinical deterioration
• Poor Collaterals
• Weigh Risks
Wire perforation
Reperfusion Injury
Distal embolization
Age
Initial infarct size
BP
Glucose
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Complications of Acute Stroke
Intervention
• Intraprocedural
Spasm
Dissection
Perforation
ICH
Failure
• Post-procedural
Reperfusion ICH
Cerebral Edema
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Perforation & Intraoperative ICH
Management
• You only have seconds
Reverse all anticoagulants/antithrombotics
Lower SBP <100mmHg
Tamponade
• Gentle balloon- don’t create bigger tear
• Occlude vessel- microcatheter, coils, glue
Leave the vessel occluded, you’ve done
enough
Call the Neurosurgeons
• But it will not do the patient any good, with rare
exception
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Post-Op Care
• No Heparin or antithrombotics X24hrs minimum
Unless emergent stent then ASA and Plavix but risk of
ICH increased
• BP Control
IV tPA <185/110
IA tPA <185/110
My Recommendations
• Recanalyzed vessel SBP<120
• Partially recanalyzed SBP<150-160
• Neuro-ICU: improved outcomes
• Repeat CT at 24hrs or with any deterioration or
new/progressive headache
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Stroke Neurologist
• Team Leader
• Protocols
• Patient Selection Criteria
• Acute Evaluation
• Treatment decisions
• Post-treatment management
• Etiology determination
• Management of Medical Complications
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Summary
• Select patients appropriately
Small necrotic core
Large ischemic penumbra
• Do not overdose pharmacological agents
• Know cerebral anatomy
Know where you are placing your device
• Use the softest, least aggressive device for the
job
• Do not put patients to sleep
• Know when to stop
Goal is neurological improvement not an open artery