How to be successful in mechanical stroke management tips and tricks

L.N. Hopkins, MD University at Buffalo Neurosurgery Distinguished Professor State University of New York

Keys to Success
Save the Penumbra
Early Dx and TxTime is Brain Medical management: BP, Statins, Antiplatelet, etc Imaging: Brain viability (Go/No Go) Analogy = STEMI (Get the artery OPEN!)
-Minimize risk of intervention

Time Is Brain Save the Penumbra Rapid Reperfusion May Reduce Neurologic Deficit

core ischemic zone ischemic penumbra

Reperfusion of the ischemic penumbra may reduce the extent of damage and improve recovery Timing is critical The average patient loses 32,000 brain cells/second

Steps for successful stroke intervention

Patient selection process:
CT: R/O hemorrhage CTA: Clot location, arch anatomy, vessel tortuosity CT perfusion: Physiological imaging for screening Guide catheters: large/flexible (Neuron, Revasc) Stent-retrievers, Penumbra (aspiration), both, ..
Conscious sedation General anesthesia for poorly cooperating patients or with respiratory compromise

Selection of devices:

Periprocedural care:

Mechanical Clot Retrieval

Evolution of acute stroke trials

Retrospective case reports and case series Prospective single-arm studies (MERCI, Multi-MERCI, Penumbra Pivotal Trial) Randomized trials (SWIFT, TREVO, IMS III)

Evolution of IA approach to revascularization

-IA thrombolysis -Mechanical thrombectomy MERCI
(Concentric Medical), 510 (k) clearance in 2004

-Aspiration thrombectomy Penumbra

(Penumbra Inc) 2008

- Stent-retrieval devices Solitaire

-(EV3/Covidien) and Trevo (Stryker) - 2012

Evolution of Endovascular Stroke Devices

Merci

Penumbra

Stents

Stentreivers

???

Stent-retrievers available StenTrievers

Solitaire AB y FR Trevo /Trevo Pro IRIIS Capture LP Opticell Aperio

REVIVE

pRESET

Pulse

Separator 3D

ReCOVER

Solitaire - Covidien
CHARACTERISTICS: - CE Mark : AB 2007, FR 2009

Advantages: detachable, parametric design

(multiple planes of clot contact)

- Disadvantages: self detachment, - 4 Available sizes - Detachable: Yes(AB), No(FR)

Trevo and Trevo Pro (Stryker)-The device

10mm Tapered Area

20mm Retrieval Area

10mm Tapered Area

40mm Total Length

3D Penumbra Device

Does using newer devices make a difference? Yes!

Review of prospective stroke trials showed improvement in revascularization from 1995 to 2012

JNIS 2012 Fargen et al

Impact of Recanalization on Outcomes

Meta-analysis of 53 studies (2066 patients total) showed a

strong correlation between recanalization and outcome

in acute ischemic stroke.

Stroke 2007 Rha and Saver

Does choosing the right device make a difference? Yes!

Example: Randomized trials comparing different types of thrombectomy devices

Data from trials vs real-world experience ENRG group data -Early post-market experience with stentretrievers (Solitaire FR) in post-FDA approval era -101 patients from 10 centers throughout the US -A variety of other approaches are used in conjunction with Solitaire FR thrombectomy
Neurosurgery 2012, Mokin et al. Under revision

Combined aspiration + stentriever thrombectomy approach

1. Stent-retriever engages the thrombus 2. The stent-retriever is retracted into aspiration catheter under continuous suction

Dumont et al., JNIS, Submitted

Combined aspiration + stentretriever thrombectomy approach

Step 1: Position aspiration catheter proximal to the thrumbus Step 2: Deploy the stent-retriever

Stent-retriever

Aspiration catheter

Potential Problem
Embolization to New Territory

Prevention Better retrievers Distal adjunctive suction Flow arrest/reversal

1

1 Solitaire

Retrospective Study. Presented at WFITN, 2011. 2 Trevo 2 Trial. Presented at ESC, 2012.

Advantages of the combined approach

1. Debris created with thrombectomy may be aspirated, preventing distal embolization 2. Aspiration catheter also acts as a distal access catheter, facilitating delivery of stent-retriever to the target lesion 3. Aspiration alone may restore flow

The Right Approach to Stroke

Time and Physiology Based

1. Choosing the right device 2. Choosing the right patient - Common criteria for IA intervention:
NIHSS 8 Onset of symptoms 0-8 hrs

- CTP significant viable brain ie. preserved CBV

Reopening the Artery works if

No Large Volume Deficit

--Q: Should every stroke with large-vessel occlusion be treated with stent-retrievers? - A: No, each stroke case should be analyzed individually. Reperfusion hemorrhage is an issue with large volume deficit

Perfusion-based patient selection

Example: two patients with left MCA occlusion and same duration of stroke symptoms

CBV

CBV

Patient 1: has penumbra and Patient 2: has volume loss likely to benefit from intervention (arrow) and no penumbra poor candidate for intervention

Data in support of perfusion-based patient selection

Turk et al, 2011: Based on CT perfusion selection, similar rates of good functional outcome and ICH were found in patients with <6 hr and >6 hr from symptom onset to endovascular procedure

JNIS 2012. Turk et al.

And more data in support of perfusion for patient selection

JNIS 2012. Rai et al.

- Utilization of CT perfusion imaging for patient selection resulted in improved functional outcomes in the recanalized population. - Outcomes of CT perfusion group were compared to MERCI, Multi-MERCI and the Penumbra trial results.

Tips and Tricks

Stroke Teamrapid triage and treatment Imaging: CT, CTA CTP (Key=Volume) -When to intervene (NIHSS; CTP) ToolsM-1 access catheters (5FR or larger) Stentrivers, stents- capture and remove clot or -Deploy stent permanently

Gates Vascular Institute

1 Acre Floorplate

Jacobs Institute Center for Innovation

Thank you!

Thank You