Stroke in India: Disease, systems, and Treatment – Interventional Treatment

Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon

MR CLEAN TrialNetherlands, 2015

ESCAPE TrialCanadian, 2015

EXTEND-IA TrialAustralian, 2015

SWIFT PRIME TrialUSA, 2015

REVASCAT TrialSpanish, 2015

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

Etiology (Indian scenario) Large-artery atherosclerosis – 41% Lacunar - 18% Cardioembolic - 10% Rare – 4% Undetermined etiology – 27%

Kaul S, Sunitha P, Suvarna A, Meena AK, Uma M, Reddy JM. Subtypes of ischemic stroke in a metropolitan city of south India (one year data from hospital based stroke registry). Neurol India. 2002;50(suppl 1):S8–S14.

ICAD

ICAD incidence - 12% (53/448) amongst ischemic strokes.

Prevalence (TCD – PSV > 140) – 7% in asymptomatic but with vascular risk factors

Kate M et al. Imaging and Clinical Predictors of Unfavorable Outcome in Medically Treated Symptomatic Intracranial Atherosclerotic Disease. J Stroke Cerebrovasc Dis 2014.

Sada S et al. Neurology India. 2014.

Indian Experience With Mechanical Thrombectomy STROKE TREATMENT CENTERS:

Thrombolysis: approx. 100 centers

Population 1,336,286,256 (July 2016 est.)Density 383 people per.sq.km (2011 est.)

Total acute stroke: 1096 (March 2002-2006) Acute ischemic stroke: 877 Thrombolysis: 54 (6.1%)

Indian Experience With Mechanical Thrombectomy

Status of Mechanical ThrombectomyAround 60 centers across country of 1.34 billion.

Among 967 patients enrolled in the on-going Indo-USA Collaborative National Stroke Registry, 134 patients came within 4.5 hours and 104 (11%) patients received r-tPA. Intra-arterial and mechanical thrombolysis was given in 34 (3.5%) patients.

Indian Experience With Mechanical Thrombectomy

Study period: 2009-2013Total cases: 45

Indian Experience With Mechanical Thrombectomy

STATUS OF MECHANICAL THROMBECTOMYPublic Sector:

AIIMS (New Delhi): 24 cases/Year.

PGIMER (Chandigarh): 18 cases/Year

SCTIMST (Thiruvanthapuram):24-30 cases /Year

NIMHANS (Bangalore): 10-12 cases/year

Indian Experience With Mechanical Thrombectomy

STATUS OF MECHANICAL THROMBECTOMY• Private Sector:

–New Delhi (single largest center): 26 cases 2015.

–Bangalore (single center): 24 cases 2015.

–Mumbai (two centers): 53 cases 2015

2013 2014 20150

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Stent - retriever

Stent - retriever

Indian Experience With Mechanical Thrombectomy

STATUS OF MECHANICAL THROMBECTOMY

Sale figures:

• Company A: 138.3 devices.

• Company B: 80devices.

• Company C: 45 devices.

Challenges …. Lack of training programs - guidelinesInsurance Stroke team Support from institutions Private sector – demand drivenPublic awareness (medical community)Timing issue

Training challenges

Dedicated training - 2 years vs ….Disciplines (Radiology, Neurology and

Neurosurgery)Centers that can train (what nos. ?)To maintain skill ??Accreditation board (STNI …)

DM Neuroradiology program centers:• AIIMS• PGI• NIMHANS• SCTIST

University • SRMC• KMC • Vellore

Fellowship program• Artemis• Medanta• MSSH • KEM Pune • Mumbai • Others….

Way ahead …Arrive at an consensus Start society authorized training program – based on minimum requirements

Approach MCI and NBE

Challenges ….Trained neurointerventionists Infrastructure Stroke team Support from institution/hospital FinancePublic awareness Timing issue

Solutions..

Program viability – aneurysms, AVMs …Overlap with neurosurgery for aneurysm, AVMs..

Overlap with neurology for ischaemic stroke …

Round the clock services INR - Three faculty – two radiology and one from

stroke neurology background . We also provide emergency services to selected centres

The stroke neurologist INR takes care of all stroke patients

Overlapping – neurology-stroke-INR teamBased on group practice One fellow – Stroke-INR fellowship

TechsEncouraged to stay nearby Training program

Anesthesia and critical care NI program is part of clinical neurosciencesActive – neurovascular program – SAHNeuroanesthesia provide cover as for HI etc

Financial barrierMost patients don’t have insurance They have to be explained in simple clear terms Major stroke, MVO, we can try to save brain, 70%

recanalization; 50% good outcome at 3-months; risk of bleed /decompression

Based on written commitment Show them picturesDetailed counseling everyday on written form Device write off….

Promoting stroke intervention program – awareness

Stroke training program for physiciansEncouraged to take opinions (social media)Neurology services to selected centers Public lectures – Rotary, Loin clubsStroke week Media TestimonialsLearning from cardiologists …

•The Interventional Management of Stroke pilot trials tested combined IV/IA therapy onset.

•Among the 54 cases, only time to angiographic reperfusion and age independently predicted good clinical outcome after angiographic reperfusion.

TIME for recanalization• Onset to door time

• Door to Imaging/picture

• Picture to puncture (P2P)

• Puncture to recanalization time

Hospital processes

Technical skills

• Onset to puncture/groin time

• Onset to recanalization time

• Door to Puncture (D2P)

• Picture to recanalization (P2R)

Society infrastructure

Ultimate predictor

One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed.

• Parallel Processing, Trust, and Teamwork

• Fast Minimalist Clinical Examination

• Fast, Minimalist Imaging Based on a Decision- Based Paradigm; No Complex Post Processing of Imaging

• No General Anesthesia

• Use the CT Angiography to Plan the Procedure

• Setting Up the Angiography Room – tech, INR, material

Physician Guide – Protocol based

Timing • Protocol• Sessions with emergency,

radiology, critical care teams• Dedicated team – INR• Monitoring

CTMRI

EDD

SA

Times pre and post implementation of parallel processing:

Picture to Puncture time: PRE Mean: 80 minutes (21 – 260) POST Mean: 60 minutes (30 – 140)

(Median – 50 minutes)

Puncture to reperfusion

POST Median 42 minutes (12 – 120)DSA next door and direct to suite – P2P – further 30 minute reduction achieved with a mean of 3o minutes

Our resultsTotal 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

Mechanical thrombectomy in India

• National guidelines • Training programs – consensus • Local solutions • Monitoring of results• Awareness ….learning from cardiology

Thank you ….