Thrombectomy for ischemic stroke and anaesthesia

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Thrombectomy for ischemic stroke and anaesthesia

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  • However > 50% do not demonstrate a favourable outcome
  • National Institute of Neurological Disorders and Stroke (NINDS) 1995
    European Cooperative Acute Stroke Study III (ECASS III) 2008
    The Prolyse in Acute Cerebral Thromboembolism (PROACT) trial 1998
    Mechanical embolus removal in cerebral ischemia. 2008
  • BACKGROUNDThrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke.Full Text of Background...METHODSThe trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS.Full Text of Methods...RESULTSIn part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P<0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30).
  • BACKGROUNDIntravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke.Full Text of Background...METHODSAfter exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events.Full Text of Methods...RESULTSWe enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P<0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P=0.008). Mortality did not differ significantly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference in the rate of other serious adverse events
  • Background and Purpose—To test the safety and recanalization efficacy of intra-arterial local delivery of plasminogen activators in acute ischemic stroke, a randomized trial of recombinant pro-urokinase (rpro-UK) versus placebo was undertaken in patients with angiographically documented proximal middle cerebral artery occlusion.Methods—After exclusion of intracranial hemorrhage by CT scan, patients with abrupt onset of symptoms of focal ischemia likely to receive treatment within 6 hours who satisfied all clinical eligibility criteria underwent carotid angiography. Patients displaying Thrombolysis in Acute Myocardial Infarction grade 0 or 1 occlusion of the M1 or M2 middle cerebral artery were randomized 2:1 to receive rpro-UK (6 mg) or placebo over 120 minutes into the proximal thrombus face. All patients received intravenous heparin. Recanalization efficacy was assessed at the end of the 2-hour infusion, and intracerebral hemorrhage causing neurological deterioration was assessed at 24 hours.Results—Of 105 patients who underwent angiography, 59 were excluded from randomization. Among the 46 patients randomized, 40 were treated with rpro-UK (n=26) or placebo (n=14) a median of 5.5 hours from symptom onset. Recanalization was significantly associated with rpro-UK (2P=.017). Hemorrhagic transformation causing neurological deterioration within 24 hours of treatment occurred in 15.4% of the rpro-UK–treated patients and 7.1% of the placebo-treated patients (2P=.64). Both recanalization and hemorrhage frequencies were influenced by heparin dose.
  • Merci Mechanical embolus removal in cerebral ischemia
    Background and Purpose— Endovascular mechanical thrombectomy may be used during acute ischemic stroke due to large vessel intracranial occlusion. First-generation MERCI devices achieved recanalization rates of 48% and, when coupled with intraarterial thrombolytic drugs, recanalization rates of 60% have been reported. Enhancements in embolectomy device design may improve recanalization rates.Methods— Multi MERCI was an international, multicenter, prospective, single-arm trial of thrombectomy in patients with large vessel stroke treated within 8 hours of symptom onset. Patients with persistent large vessel occlusion after IV tissue plasminogen activator treatment were included. Once the newer generation (L5 Retriever) device became available, investigators were instructed to use the L5 Retriever to open vessels and could subsequently use older generation devices and/or intraarterial tissue plasminogen activator. Primary outcome was recanalization of the target vessel.Results— One hundred sixty-four patients received thrombectomy and 131 were initially treated with the L5 Retriever. Mean age±SD was 68±16 years, and baseline median (interquartile range) National Institutes of Health Stroke Scale score was 19 (15 to 23). Treatment with the L5 Retriever resulted in successful recanalization in 75 of 131 (57.3%) treatable vessels and in 91 of 131 (69.5%) after adjunctive therapy (intraarterial tissue plasminogen activator, mechanical). Overall, favorable clinical outcomes (modified Rankin Scale 0 to 2) occurred in 36% and mortality was 34%; both outcomes were significantly related to vascular recanalization. Symptomatic intracerebral hemorrhage occurred in 16 patients (9.8%); 4 (2.4%) of these were parenchymal hematoma type II. Clinically significant procedural complications occurred in 9 (5.5%) patients.
  • Background: Studies of endovascular treatment for acute
    ischemic stroke have identified general anesthesia as a predictor
    for poor outcome in comparison with local anesthesia/
    sedation. This retrospective study attempts to identify
    modifiable factors associated with poor outcome,
    while adjusting for baseline stroke severity, in patients
    receiving general anesthesia.
    Methods: We reviewed charts of 129 patients treated between
    January 2003 and September 2009. The primary outcome
    was the modified Rankin Score of 0–2 for 3 months
    poststroke. Predictors of neurologic outcome included baseline
    National Institutes of Health Stroke Scale score, blood
    glucose concentration, and age. Additional risk factors evaluated
    were prolonged stroke onset-treatment interval and
    systolic blood pressure less than 140 mmHg. Choice of local
    anesthesia or general anesthesia was recorded.
    Results: The study group was 96 out of 129 patients for
    whom modified Rankin Scale scores were available; 48 patients
    received general anesthesia and 48 local anesthesia.
    The proportion of patients with “good” outcomes were 15%
    and 60% in the general anesthesia group and local anesthesia
    group, respectively (P 0.001). Lowest systolic blood pressure
    and general anesthesia were correlated (r0.7, P
    0.001). Independent predictors for good neurologic outcome
    were local anesthesia, systolic blood pressure greater
    than 140 mmHg, and low baseline stroke scores.
    Conclusions: Adjusted for stroke severity, patients who received
    general anesthesia for treatment are less likely to have
    a good outcome than those managed with local anesthesia.
    This may be due to preintervention risk not included in the
    stroke severity measures. Hypotension, more frequent in the
    general anesthesia patients, may also contribute
  • Background and Purpose—Baseline hyperglycemia has been considered an independent predictor of stroke outcome. The
    present study analyzes the dynamics of serum glucose levels within the first 24 hours and its impact on stroke outcome.
    Methods—We studied 748 patients with acute ischemic hemispheric stroke in the second European Cooperative Acute
    Stroke Study (ECASS-II). The patients had 2 serum glucose measurements, at baseline and at 24 hours. Four dynamic
    patterns were defined as baseline hyperglycemia present only at baseline, 24-hour hyperglycemia present only at 24
    hours, persistent hyperglycemia, ie, hyperglycemia at baseline and at 24 hours, and persistent normoglycemia, ie,
    normoglycemia at baseline and at 24 hours. The end points were 7-day neurological improvement on National Institutes
    of Health Stroke Scale, 30-day favorable functional outcome (Barthel Index 95 or 100), 90-day negligible dependence
    (modified Rankin Scale 0 to 2), all-cause mortality within 90 days, and hemorrhagic transformation on CT within the
    first 7 days.
    Results—In nondiabetic patients, persistent hyperglycemia was inversely associated with neurological improvement
    (OR0.31; 95% CI0.16 to 0.60), 30-day favorable functional outcome (OR0.27; 95% CI0.12 to 0.62), and 90-day
    negligible dependence (OR0.36; 95% CI0.17 to 0.73); it was associated with an increased risk of mortality within
    90 days (OR7.61; 95% CI3.23 to 17.90) and for parenchymal hemorrhage (OR6.64; 95% CI2.63 to 16.78),
    whereas it was inversely associated with hemorrhagic infarction (OR0.30; 95% CI0.13 to 0.71). Delayed
    hyperglycemia at 24 hours was associated with the risks of death (OR5.99; 95% CI2.51 to 14.2) and parenchymal
    hemorrhage (OR5.69; 95% CI-2.05 to 15.8) and inversely associated with no and negligible dependency (OR0.40;
    95% CI0.20 to 0.78). Hyperglycemia at baseline only was not associated with any parameter of worse outcome. In
    patients with diabetes, the dynamic patterns of hyperglycemia did not suggest an association with stroke outcome.
    Conclusions—Persistent hyperglycemia was associated with all bad outcome end points studied. In addition to a single
    glucose measurement, the pattern of change should be considered in the prediction of stroke outcome. ( Stroke. 2008;
    39:2749-2755.)
  • Thrombectomy for ischemic stroke and anaesthesia

    1. 1. Audit/Research projects July-December 2013. Dr Wahid Altaf Dr Sinead Galvin
    2. 2. Stroke • Sudden death of cells due to lack of oxygen. • Manifesting as focal or global disturbance of cerebral function lasting for more than twenty four hours or leading to death. • Survival of brain cells depends on time since lack of oxygen.
    3. 3. Stroke in Ireland • Annual number of stroke patients in Ireland is around 10,000.87% ischemic stroke. • Annual number of deaths from stroke is 2000. • Number of disabled patients secondary to stroke around 30,000.
    4. 4. Risk factors for Ischemic stroke • • • • Non-Modifiable Age Male sex Race Inheritance • • • • • • • Modifiable Hypertension Daibetes Mellitus Cardiac disease (AF) Cigarette smoking Obesity Increase homocysteine Inc Cholesterol.
    5. 5. Diagnosis and treatment • 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 increased neuronal loss and thereby increased morbidity. • Reperfusion remains the mainstay of acute ischemic stroke treatment .
    6. 6. Time is Brain!!!! • The average duration of non-lacunar stroke evolution is 10 hours (range 6 to 18 hours), and the average number of neurons in the human forebrain is 22 billion. • In each minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. • Compared with the normal rate of neuron loss in brain aging, the ischemic brain ages 3.6 years each hour without treatment.
    7. 7. Time is Brain!!!!!
    8. 8. Treatment options available. • IV rtPA therapy. • Mechanical clot disruption with IAT. • Thrombectomy.
    9. 9. THROMBUS
    10. 10. Mechanical thrombectomy • Recanalization by mechanical thrombectomy may occur due to combination of thrombus fragmentation, thrombus retrieval, and enhancement of fibrinolytic penetration. • FDA cleared many devices for recanalization of arterial occlusion in patients with ischemic stroke.
    11. 11. The Evidence ???? • NINDS iv tpa <3hours. • ECASS III iv alteplase 3-4.5 hours. • PROACT II ia pro uk <6hours. • MERCI thrombectomy, 8hours.
    12. 12. General anesthesia for Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy in Beaumont Hospital
    13. 13. Background • Avoid anesthesia Speed of whole process Avoid anesthetic drug effectshypotension or effect on cerebral activity • Need for anesthesia can’t be ignored. • Retrospective review on type and number of patients who got general anesthesia during last three years for clot retrieval in radio-intervention suite of Beaumont hospital. • Identify demand, issues and future.
    14. 14. Clot retrieval in Beaumont Hospital from April 2010 to Sept 2013. • Total number of cases done 107.
    15. 15. Admission route
    16. 16. GA patients admission route
    17. 17. Distribution in 24 hours
    18. 18. Demographics Male 56 Female 51 Age yrs (Average) 26-87 (62)
    19. 19. Demographics of patients for GA Male 5 Female 7 Age years (Average) 32-73(55)
    20. 20. Overall Risk factors Risk factor Number of patients High blood pressure 40 High cholesterol 18 Previous CVA 11 Ischemic heart disease 12 Atrial Fibrillation 26 Diabetes Mellitus 6 Smoking 20
    21. 21. Risk factors in GA patients Risk factor Number of patients Hypertension 6 Ischemic heart disease 2 Atrial fibrillation 2 Smoking 1 Dyslipidemia 3
    22. 22. Stroke scale of patients (NIHSS)
    23. 23. NIHSS at presentation of all patients.
    24. 24. NIHSS at presentation of GA patients
    25. 25. Stroke characteristicsVessel involved Stroke characteristics Number of patients Right sided 51 Left sided 56 Middle cerebral artery M1 59 Middle cerebral artery M2 13 Internal carotid artery 35 Basilar artery 5 Multiple vessels 42
    26. 26. Stroke characteristic of GA patients Vessel Involved Stroke characteristics Number of patients Right 8 Left 4 Internal carotid artery 6 Middle cerebral artery M1 6 Vertebral artery 1 Basilar artery 1
    27. 27. Planned Vs Rescue GA
    28. 28. IV Thrombolysis pre procedure
    29. 29. IV Thrombolysis before GA.
    30. 30. Hemodynamic parameters in GA patients during the procedure Parameter Values Range (Average) mmHg Systolic BP 100-140 (120) Diastolic BP 60-90 (65) Mean BP 73-106 (83)
    31. 31. Vasopressors used to maintain blood pressure in GA patients
    32. 32. Complications Complication Number of patients Procedural complications 15 Haemorrhage 28 Clinically significant haemorrhage 12
    33. 33. ICU Admission post procedure of GA patients
    34. 34. MRS at 3 months.
    35. 35. MRS of GA patients
    36. 36. Prognosis overall
    37. 37. Prognosis of GA patients
    38. 38. Prognosis with intra-op Blood pressure Mean Arterial BP (mmHg) Survived Dead Unknown < or= 80 1 4 1 >80 5 1 0
    39. 39. Issues important to us. • • • • Increasing demand over the years. Out of hours service needed. High ASA grade of these patients. Failed IV thrombolysis before clot retrieval and consequences thereof. • Internal carotid and middle cerebral artery involvement in majority. • Hemodynamic parameters to target/Blood glucose control and means to achieve the same/maintaining normothermia. • Need for ICU/Ventilation post procedure.
    40. 40. Future • Our demand to provide anesthesia for sick patients may increase with time. • Develop standard procedures and protocols. • Canadian multi-centric trial for outcome from clot retrieval. • Clot retrieval in interventional cardiology.
    41. 41. Quality improvement maneuver • Safer and standard anesthetic practice Standard monitoring as per AAGBI. IV canula with IV fluids running via 3 way tap. Anesthetic machine checked every day and ready in high risk patients. Emergency drugs/Airway tray ready to use.

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