What is the best imaging protocol for LVO screening when ...€¦ · recommendation: strong)....
Transcript of What is the best imaging protocol for LVO screening when ...€¦ · recommendation: strong)....
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Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention
Zentrum für Radiologie und Endoskopie
Jens Fiehler, MD, FESO
What is the best imaging protocol for LVO screening when outside of 0-6h window?
WLNC, Los Angeles/CA, USA, May 15-17, 2017
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Research support: EU, BMBF, BMWi, Microvention
Presentations: Bayer, Boehringer, Bracco, Codman, Penumbra, Sanofi, Siemens, Stryker
Consultancy: Acandis, Covidien/Medtronic, Medina, Microvention, Penumbra, Stryker, Sequent
Disclosures
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“If you wish to converse with me, define your terms.” saidVoltaire, “
How many a debate would havebeen deflated into a paragraph ifthe disputants had dared to define their terms!
—Will Durant
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Imaging based patient selection: Expectations for selected subjects
Good outcomeHigh complication rates, start therapy, new indication, limited MT ressources
High therapy effectSome economic restrictions
Potential therapy effectLow complication rate, training center, economicincentives
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Principles The lucky few The majority The wasteland
Good outcome
Proximal occlusion
Proximal occlusion
Small core
Eyeballing withlittle software
support*
Eyeballing withmore software
support*
High therapy effect
Proximal occlusionProximal occlusion
Medium coreEyeballing only Eyeballing only
Potential therapy effect
Any occlusion
Any occlusionLarge core
Eyeballing only Eyeballing only
Where are you?
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Modify expectations: Skills and infrastructure
The lucky fewHigh-end imaging 24/7/365 availableExcellent interpretation skills 24/7/365 available
The majorityMixed quality of CT/MRI equipmentAlways some new Radiologists
The wastelandOld NE-CT, „CTA-resistance“Unfriendly radiologists, no interest in stroke
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Principles The lucky few The majority The wasteland
Good outcome
Proximal occlusion
Proximal occlusion
Small core
Eyeballing withlittle software
support*
Eyeballing withmore software
support*
High therapy effect
Proximal occlusionProximal occlusion
Medium coreEyeballing only Eyeballing only
Potential therapy effect
Any occlusion
Any occlusionLarge core
Eyeballing only Eyeballing only
Where are you?
*Vendors, RAPID, Brainomix, …
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Pipes Perfusion Infarct
OcclusionCollaterals
„Tissue at risk“ Ischemic core
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F/U
Infarct
acute
Why recanalise a M1 occlusion?
Full success!Infarct volume 18 cm3
mRS (90) 5→0
Futile recanalisationInfarct volume 402 cm3
mRS (90) 5→5
„Sub radar success“Infarct volume 124 cm3
mRS (90) 5→3
Differentiate between predictingGood outcome and therapy effect!
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ASPECTS on tissue damage?
Menon, B et al. Neuroimag Clin N Am 2011;21: 407–23.
Yoo YA et al. Stroke. 2012;43:1323-1330.
10 ROI count-down
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3 hrs
27 hrs 4 days
DWI TTP CBV CE-MRA
Ischemic core: lesions can grow for days
*74 y female, M1-occlusion, 2010, no recanalization because of „no mismatch“
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#1: Ischemic core: lesions can grow for days
3h 27 h 5 d
*74 y female, Carotid-T-occlusion, 2002, IA tPA without recanalization
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• Occlusions of MCA (M1 or M2) and/or of the intracranial ICAshould be diagnosed with non-invasive imaging whenever possible before considering treatment with EVT. (Quality of evidence: high, Strength of recommendation: strong).
• EVT can be considered in patients where there is an occlusion or stenosis of the cervical ICA in addition to a suitable intracranialtarget vessel occlusion (tandem pathology). (Quality of evidence: moderate, Strength of recommendation: strong).
• The additional benefit of advanced perfusion or collateral image processing for patient selection is not established and requires further study. (Quality of evidence: low, Strength of recommendation: strong).
EROICAS (ESMINT, EANS, ESNR, ESO, EAN, EuSEM)Which imaging selection criteria?
Fiehler J et al. Int J Stroke. 2016 Aug;11(6):701-16.
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Yoo AJ et al. Lancet Neurol 2016; 15: 685–94
MR Clean: ASPECTS vs. MT effect
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HERMES*: Meta-Analysis of individual patient data
Goyal M, et al. Lancet. 2016 Feb 18.
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Clinical18–80 years, NIHSS score 10–25, IV tPA <3h (later <4h), MT start <5h
Imaging CTA/MRA: occlusion of ICA, M1, superior third of basilar artery, cervical ICA occlusion excludedNo ASPECTS limit
Confirmation from France: THRACE
Bracard, S et al. Lancet Neurol 2016 Oct;15(11):1138-1147. Epub 2016 Aug 23. Mechanical thrombectomy after intravenous alteplaseversus alteplase alone after stroke (THRACE): a randomised controlled trial.
+11%
mTICI 2b–3: 69%
RCT, 414 patients from 26 centres in FranceDuration: 06/10-02/15
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ASPECTS mentioned just under „Additional information“:
• The ASPECTS score has only moderate to good interobserveragreement in the hyperacute stroke setting.
• In patients with lower initial ASPECTS, the location of the hypodensity can be taken into consideration. No treatment interaction with ASPECTS has been demonstrated but ASPECTS 0-4 are barely represented in recent trials.
• Further RCTs in patients with ASPECTS 0-5 are warranted.
EROICAS: Imaging criteria for thrombectomy
Fiehler J et al. Int J Stroke. 2016 Aug;11(6):701-16.
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Ischemic core volume and outcome in MR Clean
Borst J, et al. Stroke. 2015 Dec;46(12):3375-82.
45%
8%
<70 mL
≥70 mL
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Ischemic core volume and outcome in MR Clean
Borst J, et al. Stroke. 2015 Dec;46(12):3375-82.
47% mRS 0-3
30%
10%
<70 mL+9%
≥70 mL+37%
61% mRS 0-3
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1h 2h 3h 4h 5h 6h 7h 8h 9h 10h 11h 12h
T.A.
F.G.
Z.X.
H.G.
P.I.
B.W.
Volumen
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1h 2h 3h 4h 5h 6h 7h 8h 9h 10h 11h 12h
T.A.
F.G.
Z.X.
H.G.
P.I.
B.W.
Volumen
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Onset to treatment time vs. treatment effect
InfarctVolume
The Ischemic Penumbra
Baron, Cerebrovasc Diseas 1999
Saver JL, et al. JAMA. 2016 Sep 27;316(12):1279-88.
Average volume!Which patients?
1995IV old(3:00)
2008IV new(4:30)
2015MR Clean
(6:19)
2016 HERMES: 7:18 h
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48h F/U
image groin
recanalisation
dooronset
90dmRS
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CT
5h 10h Recan
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
Onset
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OnsetCT
5h 6h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
Recanalization
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Onset RecanalizationCT
5h 7h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Onset RecanalizationCT
5h 8h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Onset RecanalizationCT
5h 9h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Onset RecanalizationCT
5h 10h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Onset RecanalizationCT
5h 11h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Onset RecanalizationCT
12h
48h follow up
Kemmling A et al. 2015 Sep; 35(9):1397-405.
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Probability of mRS score of 0-2
Ribo, M. et al. Stroke. 2016;47:999-1004.
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Probability of mRS score of 0-2
Ribo, M. et al. Stroke. 2016;47:999-1004.
?
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Ribo, M. et al. Stroke. 2016;47:999-1004.
Probability of mRS score of 0-2
% o
f m
RS
(90
d)
?
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Menon BK et al. Circulation. 2016;133:2279-2286.
ESCAPE: only P2P counts … ?
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Saver JL, et al. JAMA. 2016 Sep 27;316(12):1279-88.
HERMES: Delay vs. mRS 0-2 (90 d)
Absolute risk reduction (per h): 14%
Absolute risk reduction (per h): 0
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1
2
3
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5
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5
1
2
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4
3h
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4h
3
5h
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60%mRS 0-2
1
2
3
4
5
1
2
3
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5
1
2
3
4
3h
1
2
4h
4 x 60% ChancemRS 0-2
48%mRS 0-2
3
3 x 60% ChancemRS 0-2
36%mRS 0-2
5h
5 x 60% ChancemRS 0-2
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20
30
40
50
60
70
3h 4h 5h
All patients
Study patients only
% m
RS
0-2
(9
0d
) Time from symptom onset (h)
60%
48%
36%
Time: all patients or just the chosen few …
Fiehler J. The Time-Reset Effect. Clin Neuroradiol. 2017 Jan 25.
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20
30
40
50
60
70
3h 4h 5h
All patients
Study patients only
% m
RS
0-2
(9
0d
) Time from symptom onset (h)
60%
48%
36%
Time: all patients or just the chosen few …
Fiehler J. The Time-Reset Effect. Clin Neuroradiol. 2017 Jan 25.
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20
30
40
50
60
70
3h 4h 5h
All patients
Study patients only
% m
RS
0-2
(9
0d
) Time from symptom onset (h)
60%
48%
36%
60% 60% 60%
Time: all patients or just the chosen few …
Fiehler J. The Time-Reset Effect. Clin Neuroradiol. 2017 Jan 25.
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20
30
40
50
60
70
3h 4h 5h
All patients
Study patients only
% m
RS
0-2
(9
0d
) Time from symptom onset (h)
60%
48%
36%
60% 60% 60%
Time: all patients or just the chosen few …
Fiehler J. The Time-Reset Effect. Clin Neuroradiol. 2017 Jan 25.
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• Time from symptom onset to groin puncture should be preferably within 6 h. (Quality of evidence: high, Strength of recommendation: strong).
• Time from symptom onset to groin puncture should be no later than 12 h. Advanced imaging might help in identifying patients with potential benefit in the 6–12 h time window. (Quality of evidence: very low, Strength of recommendation: weak).
• Application of an upper age limit is not justified. (Quality of evidence: high, Strength of recommendation: strong).
EROICAS: Which clinical selection criteria define candidates for additional thrombectomy compared to best medical therapy alone?
Fiehler J et al. Int J Stroke. 2016 Aug;11(6):701-16.
DAWN studyPresented at ESOC 05/2017
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Stroke imaging
Proof of occlusion: mandatory
Define your terms: core is kingGood outcome vs. therapy effect vs. avoid harm
Know your limitations: reading aids helpful?
Time is brain: but there is no limit„Good brain“ is time invariant