Thrombectomy for ischemic stroke · a broad range of ischemic stroke patients with large vessel...
Transcript of Thrombectomy for ischemic stroke · a broad range of ischemic stroke patients with large vessel...
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Thrombectomyforischemicstroke
ProfBruceCampbell
ConsultantNeurologistandHeadofStrokeRoyalMelbourneHospital
ProfessorialFellow,[email protected]
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Disclosures Financialdisclosures–none
Off-labeluseoftenecteplaseforischaemicstroke
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Learningobjectives Understandtheevidencebehindthrombectomyeligibility– siteofvesselocclusion– age– severity– time
Understandimagingstrategiesandtheprognosticsignificanceofischemiccorevolume
UnderstandtheroleofIVthrombolysisbeforethrombectomy– 0-4.5hrversus>4.5h
UnderstandthecriticalimportanceofSystemsofcareinmaximisingpatientoutcomes
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Keymessages Endovascularthrombectomy(EVT)profoundlyreducesdisabilityin
abroadrangeofischemicstrokepatientswithlargevesselocclusion0-6hafterstrokeonset
EVTalsobenefitsselectedpatientswithfavorableperfusionimagingupto24hafterstrokeonset
CurrentlyEVTiscombinedwithIVthrombolysisineligiblepatients(withongoingtrialstestingEVTaloneinpatientspresentingdirectlytoEVTcenters)
Fastertreatmentisthemosteffectivewaytoimprovepatientoutcomes–streamlinetransfersandminimizere-imaging
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Largevesselocclusion-thrombolysisvsthrombectomy
Thrombolysisonly
Thrombectomyonly
Thrombolysis&Thrombectomy
*“LVO”definitionmaychangewithdeviceimprovements
**plannedtrialstoaddIVlysistothrombectomy>4.5hr
>70%-noreperfusiontherapysuper-mild,established,verylate
largevesselocclusion(LVO) 15%ofallstrokebut 39%ofacutelypresentingstroke responsiblefor62%ofdependencyand
96%ofmortality(MalhotraFrontNeurol2017)
IVthrombolysishaslimitedefficacy
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NewEngJMed2015: 5Positiverandomizedtrials 2Editorials Faster,betterreperfusion MoreImaging
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Whichsitesofvesselocclusion?
ICAandM1–benefit tandemdisease(cervical+intracranial)–benefit ?M2 lesscommon,highlyvariableanatomy
smaller,moretortuous,lessaccessible
lessterritoryatrisk
greaterresponsetoIVthrombolysis
HERMESmeta-analysis=larger/dominant/moreproximalM2withhigherNIHSSbenefit–needtoindividualizedecision
M3/4,ACA,PCA-?? Basilar–excludedfrommosttrials,BEST20%benefit“astreated”,
BASICSRCTongoing.timewindow:?24hrfromlastknownwellvs~8hrfromonsetofcoma
ICA M1
?M2
not M3/4?
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GoyaletalLancet2016
Agelimits?
AgeisprognosticAgedoesnotmodifytreatmenteffect
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Severitylimits?
GoyaletalLancet2016
NIHSSisprognosticNIHSSdoesnotmodifytreatmenteffectUncertaintyinverymild(NIHSS0-5)àENDOLOWtrial
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Thrombectomy– stilltimecritical
FransenJAMANeurology2016
MRCLEANselection(CTAocclusion)withsuccessfulreperfusion
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Thrombectomy– stilltimecritical
7.3hrs
2.3 2.5 2.9
3.4 4.2
5.5 8.6
NNTs
SaverJAMA2016
Forevery4mindelayafterreachingemergency1in100patientswillhaveincreaseddisability
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IschemicPenumbra–thereasonwecanimproveoutcomeafterischaemicstroke
Astrup,Symon1977
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CTperfusion–diagnosisandprognosis
DelayedTTP/Tmax=collateralterritory
timeAreaundercurve≈0
conc
entr
atio
n
timeArea=CBV
TTP
conc
entr
atio
n
CBVLowCBV
=likelyirreversiblydamaged
CBF TTP
DiffusionMRI
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AutomatedCTperfusionprocessing
“Howmuchbloodsupply”(severelyreduced≈dead)
relCBF<30%ofnormalbrainCampbelletalStroke2011
*timetoreperf&greyvswhitematter
“Howdelayedisthebloodsupply”(severelydelayed≈atrisk)
iSchemaViewRAPIDversion4.7
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NogueiraNEJM2017
ordinalNNT2.0mRS0-2:49%vs13%,p<0.000184%mTICI2b/3SICH5.6%vs3.0%,p=0.50
ordinalNNT2.1
mRS0-245%vs17%,p<0.000176%mTICI2b/3SICH6.5%vs4.4%,p=0.75
AlbersNEJM2018
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DAWNeligibilityeffectinDEFUSE3
AlbersetalNEJM2018
DEFUSE3criteria simpler ~60%morepatientseligible
Noreductionintreatmenteffectwithinage,NIHSSorcorevolumesincluded
i.e.6-24hrwithICA/M1and<70mLcoreàthrombectomy
DAW
Ne
ligib
le
no
tDAW
Ne
ligib
le
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Istimestillbrain?
Overallstrokepopulationareverytimesensitive–stillneedtogoasfastaspossible
Theproportionofpatientswhoremaineligiblebyimagingcriteriadecreasesovertime(~50%ofLVOinthe6-24hrtimewindowbasedonDEFUSE3screening)
However,ifanindividualpatientisunavoidablydelayedinpresentationANDimagingisstillfavorablethentheyarelikelytobenefitfromreperfusion
Yes!
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advancedimagingisnotjustabout“excluding”patients includingmorepatients
– mildNIHSSbutsignificantperfusionabnormality– late/unknowntime– “lowASPECTS”butonlymoderatevolumeNCCTchanges– clinically“marginal”butgoodimaging
AND diagnosticbenefits
– whenpatientspresentthefirstquestionis“isitstroke”– variablelevelsofexperienceonground,in-hours,after-hours,telemedicine– improvedNCCTinterpretationwhenyouknowwheretoscrutinize– LVOmaybechronic,partial,asymptomatic–perfusioncanhelp
AND Maybeinfuturewewillhavenon-reperfusion-basedtherapies…
– glyburide,NA1etcmightbenefitfromimagingtotargetthosenotlikelytodowelljustwithreperfusion
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ImpactofCorevolume,AgeandTime(imagingtoreperfusion)onfunctionaloutcomeinpatientssuccessfullyreperfused
0 20 40 60 80 100
Age (years)
40
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60
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90 Imag
ing to
repe
rfusio
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% m
RS 0-2
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Age (years)
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ing to
repe
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% m
RS 0-2
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10mlcoremRS0-2 100mLcoremRS0-2
Age (years)
40
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repe
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% m
RS 0-30
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100mLcoremRS0-3
For0-6hourpatientsdon’texcludepurelyonbasisofcorevolume:Balancecorevolumeandlocation,expectedtimetoreperfusion,pre-morbidstatus&toleranceofdisabilityifknown CampbelletalLancetNeurology2019
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AllthepositiveRCTsadministeredalteplasetoalleligiblepatients…anditdoeshaveaneffect:
Ifeligibleforbothtreatmentsshouldwestillgivethrombolysisbeforethrombectomy?
IV-IAbridging DirectIA
potentialbenefitiffailure/delayinendovascularprocedure
potentialreductioninsymptomaticintracerebral(andsystemic)hemorrhage
potentialbenefitindissolvingdistalembolicfragmentsofthrombus/multi-territoryemboli
potentialreductionindistalmigration/fragmentationofthrombus“outofreach”priortoendovascularprocedure
potentialforpre-endovascularreperfusion savecostofalteplase/tenecteplase
Intervention Alteplase Standardcare
FinalReperfusionTICI2b/3[AngioCorelabdetermined]
77% --- ---
mAOL2-3(at2-8hCTA)[CTCorelabdetermined]
--- 37% 7%
GoyaletalESCAPE,NEJM2015
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Meta-analysisofobservationaldata
MistryStroke2017
NBmostly“direct”patientswerelysis-ineligiblepatientsintendedforthrombectomywhorecanalizepriorwerenotincluded…
mRS0-2
DEATH
Recanwith≤2devicepasses
Recanalization
?thrombolysisfacilitatesthrombectomyevenifreperfusionnotachievedpriortoprocedure
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SystemsofCare–TimeisBrain!
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ConclusionsRapidreperfusionremainstheproventreatmentparadigminstroke Currentlythrombolysis+thrombectomyifeligibleforboth(DIRECTtrialsongoing)
ThrombectomyforICA,M1,tandem,basilar,selectedM2occlusions “Good”premorbidfunction Noageorclinicalseveritylimits 0-6h:broadimagingcriteria6-24h:DEFUSE3imagingselection<70mLcore CTperfusionisdiagnosticandcharacterizesirreversiblyinjuredcore/collaterals
-veryhelpfulforprognosisinanytimewindow Simplydeliveringthrombolysis&thrombectomyfasterandincreasingaccessto
appropriatepatientsisessentialtomaximizeeffectiveness–focusonsystemsofcare
~