Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy

1. Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy Dr Sanjeev Nayak Consultant Neuroradiologist

2. Introduction • Stroke is the major cause of disability in the developed world • In the UK it accounts for 11% of deaths, it results in significant morbidity of people who survive and represents a substantial health and resource problem (NICE 2009) • Its early diagnosis is important as its treatment is dependent on the time elapsed since the onset of the symptoms. Delay in diagnosis and treatment translates into increase neuronal loss and thereby increased morbidity. • Reperfusion remains the mainstay of acute ischemic stroke treatment [4]

3. IV rtPA therapy for acute ischemic stoke improves 3-month outcome if given within 3 hours of onset. • However > 50% do not demonstrate a favourable outcome • In several series mechanical clot disruption with IAT has been shown to achieve higher recanalization rates.

4. Stroke in STOKE Period : Jan 2010 to August 2010 (8 Months) Total Number of Acute Strokes: 758 patients Patients treated with IV rtPA : 39 patients Patients treated with IA rtPA ± Mechanical thrombectomy : 18

5. Subjects and Methods: A review of 18 patients presenting to our institution over a period of 8 months with acute stroke where CTA confirmed the presence of a thrombus These patients were resistant to IV rtPA and underwent partial to complete clot removal either with IA thrombolysis or in conjunction with mechanical thrombectomy. 13 of the 18 patients underwent mechanical thrombectomy Solitaire AB device was used in 12 of the 13 patients Thrombus-aspiration and guide wire thrombus dislodgement was attempted in 1.

6. Clinical Protocol: • Neurological examination was performed on all acute stroke patients either by a neurologist or a stroke physician. • Main Inclusion Criteria: • Anterior Circulation Strokes: • Age < 80 yrs • NIHSS ≥ 8 • Onset of symptoms within 8 hours of treatment • No large hypodensity on plain CT Head • Occlusion of a major cerebral artery on CT Angiogram • Posterior Circulation Strokes: • Time window extended up to 12 hours • No haemorrhage on presenting CT Head.

7. An admission and post-interventional NIHSS score calculated on all patients. A 30-day MRS was then recorded on all these patients. Clinical follow-up and rehabilitative care was then undertaken through a multi-disciplinary approach

8. Imaging Protocol: • All patients underwent plain CT Head and CTA arch to COW • Patients with intracranial major vessel/cervical carotid occlusion secondary to a thrombus were included for the intervention • Occlusion were either present at proximal M1 segment of MCA, M1/M2 junction, terminal ICA or basilar occlusion • TIMI scores were recorded post procedure • Post procedural CT was performed at 24 hours and repeated at necessary intervals depending on the clinical status of the patient.

9. Anti-thrombotic protocol • 0.9 mg/Kg rtPA is the total dose per patient • Of which 0.6 mg/kg is adminsterted IV upon clinical and imaging diagnosis of acute stroke (Bridging dose) • 10% of the IV dose is given as a bolus. • 0.3 mg/Kg is given intra-arterially in the neurointerventionalangio suite. • A maximum of 30 mg rtPA is administered intra-arterially • 3 of our patients did not receive rTPA and only mechanical thrombectomy was performed in them. *One fell off the CT table and there was concern about any bleed *In other 2 the time of onset of symptoms was not known

10. Thrombectomy Protocol using a Solitaire AB device • Interventions performed via femoral approach • 6F guiding catheter placed in ICA/Vertebral artery • DSA performed to visualise the location of thrombus • Clot passed with a microwire and a 18 microcatheter • Super selective contrast injection performed via the microcatheter to define the distal end of the clot. • Solitaire AB device was then placed within the clot for 3-5 m • Entire system withdrawn back into the guiding catheter with 50mls of negative suction applied at the level of guiding catheter • Up to 3 attempts performed

11. 46 yr. old male with presenting NIHSS score of 15

12. Micro catheter Run Solitaire-AB in position

13. NIHSS improved from 15 to 3

14. PRE AND POST

15. THROMBUS

16. Treatment options for patient presenting with signs and symptoms of acute cerebral ischemia in our Institute • <12 hours since onset of PC symptoms • <80 year-old • 6-8 hours since onset of AC symptoms • < 80 year-old CT: no established infarction CT: no bleed No contra-indication* CTA • Thrombus on CTA: • bridging IV thrombolysis with 0.6mg/kg • + remaining 0.3 mg/kg IA on table • +/-thrombectomy

19. Results • Time of onset to A&E presentation • Anterior Circulation (12 patients) : 40 min to 310 min (Median value 150 mins) • Posterior Circulation (6 patients) : 55 min to 650 min (Median value 300 min) • 1 patient with no known time onset. • Common Presenting Symptoms: • Anterior Circulation: Dense hemiparesis, neglect, dysphasia • Posterior Circulation: Headache, profound ataxia, cranial nerve palsies, collapse • CT Head : No established infarction or intracranial bleed. • CTA : Major intracranial vessel occlusion

20. Time to Treatment (A&E to angio suite): 60 min to 280 min (median 105 min) Duration of Interventional Procedure: 60 min to 240 min (median 102 min) Mechanical Thrombectomy: 13 of 18 patients (Solitaire 12 patients) Number of passes with Solitaire: 1 to 4 passes (median 2 pass) 12 Anterior Circulation Strokes: Admission NIHHS: Between 8 and 31 (median 16)

21. AOL recanalization and TIMI reperfusion scoring system from IMS I review AOL indicates arterial occlusive lesion; TIMI, Thrombolysis in Myocardial Infarction

22. Anterior Circulation Strokes (12 patients):

23. Anterior Circulation Strokes (12 patients) MT performed in 10 patients (Solitaire) TIMI 3 recanalization: 8 (80%) * MT aborted in 1 patient due to anaesthetic concerns * MT unsuccessful in 1 patient

24. Anterior Circulation Strokes (12 patients) • Improvement in NIHHS score of ≥ 4 : 10 patients (83.33%) • Discharge MRS of ≤ 2 : 7 patients (58.33%) • Discharge MRS of 3: 1 patient (8.33%) • Discharge MRS of 4 : 4 patients (33.33%) • *MT not performed in 1 patient (only IA given) • *MT aborted in 1 as the anaesthetist raised concerns of bleeding • *MT performed in 1 but no revascularisation acheived. • *MT successful in 1 but developed patchy infarction.

25. Posterior Circulation Strokes (6 patients) :

26. Posterior Circulation strokes (6 patients) 3 patients underwent MT (50%) 3 treated with IA (50%) Complete Recanalization (TIMI 3) : 5 patients (83.33%) Discharge MRS of ≤ 2 : 4 patients (66.66%) MRS of 4 : 1 patient MRS of 5 (Locked in) : 1 patient

27. REVIEW OF 18 CASES • OUR RESULTS: Recanalization  Rates : (TIMI III72%) Recanalization achieved with Solitaire Device : 91%TIMI III Discharge mRS of ≤ 2 : 11 patients (61%)   • Multi Merci Trial Recanalization Rates (TIMI II/III) : 68% (TIMI III not reported) mRS scores ≤ 2: 36% • Penumbra Trial Recanalization Rates (TIMI II/III:82% ) (TIMI III: 27%) mRS scores ≤ 2: 25%

28. 72 year old male, NIHSS improved from 22 to 6 in 24hrs

29. 43 yr. old male, Mr L, Presented at 21:45 hrs. Friday night

30. 1st Pass with Solitaire Device

31. Intra-Arterial with 23mg rtPA 2nd Pass with Solitaire

32. Complete revascularization, NIHSS improved from 15 to 0 Patient Discharged on Sunday afternoon!!

33. 61 yr old male found collapsed GCS 4

35. 2 passes with Solitaire

36. IA rtPA Complete Revascularization

37. Modified Rankin Scale 1 2 3 4 5 No Mild Moderately Severe Moderate Severe Independent Dependent

38. Conclusion • Early interventions in acute stroke reduces patient morbidity and mortality and is extremely cost-effective. • Always aim to achieve complete revascularisation in suitable patients • The relationship betweenreperfusion and clinical outcomes, is not linear and depends on other factors including intensity andduration of the ischemia, baseline stroke severity, collateralcirculation, cerebral perfusion pressure, lesion location andlesion volume