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ppt

1. Thrombectomy in Acute
Stroke
Christopher J. White, MD, MSCAI
Prof and Chairman of Medicine
Ochsner Medical Center

2. Disclosures: Stroke Intervention
•Research: None.
•Speakers: Nada.
•Stock: Zero.
•Consultant: Nothing.
Christopher J. White MD

3. Ischemic Stroke Therapy
•IV Thrombolysis
–≤ 4.5 hrs from onset.
–Widely available.
–Restricted population.
•No bleed on CT.
•SBP < 185 mmHg
•DBP < 110 mmHg
•Low bleeding risk.
•Mechanical
Thrombectomy
–≤ 6 hrs from onset.
–ASPECTS > 6.
–Large vessel occlusion.
–Disabling strokes (NIHSS > 5).
•MCA occlusion.
•Speech impaired.
•Vision impaired.
PATIENT SELECTION

4. National Institute of Neurological Disorders and Stroke rt-PA Study Group
NEJM 1995;333:1581-7.
NINDS Trial
•624 pts randomized within 3 hrs.
★Placebo
★Rt-PA 0.9 mg/kg (max 90 mg) over 1 hr.
•Neurological assessment
★TPA increased full recovery rate 21% to 34% (32%
relative) at 3 months (OR=1.7 (95%CI 1.2-2.6) p=
0.008).
★Mortality not different between groups.
★IC bleed rt-PA 6.4% vs 0.6% (p < 0.001).
M2
BASELINE
IV-tPA
10x

5. •The initial trials did not demonstrate
conclusive benefit for endovascular
therapy, although there were
promising signals.
•There seemed to be a balance
between early and effective
mechanical reperfusion with the risk of
intracranial hemorrhage (ICH) that was
related to reperfusion of nonviable
brain.
•MERCI
•MR RESCUE
•SYNTHESIS EXP
•IMS-III
EARLY TRIALS: Mechanical Thrombectomy

6. •No benefit for MT ± IV-TPA vs. IV-TPA in
moderate to severe acute ischemic stroke.
•However, there were significant weaknesses.
★CTA was not required, which allowed the
inclusion of patients who did not have
intracranial large-vessel occlusion.
★First generation MT devices used.
IMS-III: Early Trials
Interventional Management of Stroke
Merci
Retriever

7. •Between December 2014 and April
2015, 5 RCTS provided compelling
evidence that mechanical
thrombectomy (MT) improves
outcomes after acute ischemic stroke.
•MT significantly improved clinical
outcome in patients with proximal
intracranial occlusion of the anterior
circulation compared with IV t-PA.
PARADIGM SHIFT
•MR CLEAN
•ESCAPE
•EXTEND IA
•SWIFT PRIME
•REVASCAT

8. ★CTA to select patients with LVO.
★Select viable brain (penumbra).
★Stent retrievers for thrombectomy.
EVOLUTION OF STROKE Rx
Papanagiotou P. and White C. J Am Coll Cardiol Intv. 2016; 9(4):307–17.
The major differences between these positive
endovascular trials and past trials were:

9. Strategy: Early Treatment
Khandelwal P, et al. J Am Coll Cardiol 2016;67:2631–44.
Time to Rx
Reperfusion Flow

10. Strategy: Effective Reperfusion
Khandelwal P, et al. J Am Coll Cardiol 2016;67:2631–44.
Good Reperfusion
Good Neurologic Outcomes
NNT

11. META-ANALYSIS
Hong KS, et al. J Stroke. 2015 Sep; 17(3): 268–281
Pooled estimates for achieving modified Rankin Scale (mRS)
0-2 outcomes with Endovascular Recanalization Therapy vs.
Control.

12. SUMMARY
•Shorter times to reperfusion.
•Improved patient selection.
•Better thrombectomy devices.
Khandelwal P, et al. J Am Coll Cardiol 2016;67:2631–44.
OPTIMAL MANAGEMENT OF ACUTE ISCHEMIC
STROKE
•Onset to Rx ≤ 6hrs
•Stent Retrievers
•Aspects ≥ 6
•NIHSS ≥ 5
•Large Vessel Occlusion