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Ken Faulder: Clot Retrieval and the Future of Stroke

Ken Faulder: Clot Retrieval and the Future of Stroke



Faulder weighs in on intraluminal therapy in acute stroke management.

Faulder weighs in on intraluminal therapy in acute stroke management.



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    Ken Faulder: Clot Retrieval and the Future of Stroke Ken Faulder: Clot Retrieval and the Future of Stroke Presentation Transcript

    • Mechanical thrombectomy and the future of stroke Dr Ken Faulder Interventional Neuroradiologist Westmead and Royal North Shore Hospitals
    • N/A IncidenceRate(%) IV-rtPAPlacebo NINDS* (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group) *AJNR 30:859-75: May 2009 NINDS demonstrated that IV-tPA is safe and more effective than Placebo in the 0-3 hour window. 28.0% 24.0% 1.0% 39.0% 21.0% 7.0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Recanalization GoodOutcome(mRS0-1) Mortality SymptomaticICH
    • N/A IncidenceRate(%) IV-rtPAPlacebo ECASS III (European Cooperative Acute Stroke Study) N Engl J Med. 2008 Sep 25;359(13):1317-29. ECASS III extended the window of care for IV tPA treatment to 4.5 hours. 49.2% 8.4% 0.2% 52.4% 7.7% 2.4% 0% 10% 20% 30% 40% 50% 60% Recanalization GoodOutcome Mortality SymptomaticICH
    • IV tPA – Recanalization at One Hour (angiographic data) Del Zoppo et al.,Ann Neurol 1993 • IV-rtPA recanalization rates for large vessel occlusions in comparison to smaller vessel occlusions is lower. 31% 8% 24% 35% 40% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% All ICA MCAStem MCADivsn MCABranch %Recanalized
    • Effect of site of occlusion on clinical outcome  Published June 21, 2012 as 10.3174/ajnr.A3149
    •  Strokes treated in NINDS trial in fact a heterogenous group  Perforator, M3, M2, M1, ICA  TPA does not work in long M1 or ICA occlusions,TPA wrong treatment and prevents or delays correct triage to IA treatment
    • REVASCULARIZATION AND GOOD OUTCOME Rha Meta-analysis Recanalized: 58% good outcome Non-recanalized: 25% good outcome 53 studies, 2066 patients Morbidity and mortality at 3 months Strong association with recanalisation & good outcome Recanalisation is appropriate biomarker of therapeutic activity Stroke 2007
    • Variability and reversibility of focal cerebral ischaemia in unanesthetized monkeys Cromwell RM et al Stroke lab, Uni of Massachusetts Neurology October 1981 31(10):1295-1302 ‘neurologic improvement was common after the release of occlusion. …frequent with 30-min and 4- hour occlusions …was observed even after 16 hours’
    • Time is Brain - Quantified  1.9 Million Neurons lost every minute  Calculations on growth function of a ‘typical’ large vessel ischaemic stroke  Used ‘linear growth function’ to calculate neuronal loss over time  Personal observation is that if there is recanalization, final infarct refects core volume at time of perfusion, raises question whether infarct growth linear J Saver - Stroke 2005
    • 70 yo man, acute left hemispheric stroke, presents at 2 hours Is this patient better off if given TPA?
    • Poor outcome in patients defined as malignant perfusion had poor outcome (100%) vs non malignant scans (7.1%) Stroke 2012;43:0-0
    • 72 yo woman dense left hemiplegia 4 hrs post onset, NIHSS 12
    •  The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke Miteff F et al Brain 2009:132:2231-2238
    • Evolution of technique  Early days of IA lysis, patients treated with intra-arterial rTPA or Urokinase  ProAct II, clinical outcomes promising but concern over incidence of symptomatic intracerebral haemorrhage ~10%  Early mechanical devices initially promising but difficult to use, long procedures and 70-80% recannalization
    • Evolution of technique  IMS III ◦ Trial comparing IV thrombolysis and combined IV thrombolysis and intraarterial clot retrieval ◦ Early 2012, study stopped early because of futility ◦ Several criticisms of study design, most importantly 1st generation devices, Merci, Ekos ◦ Secondly, time delay to institution of IA
    • AJNR Am J Neuroradiol. 2011 Jun-Jul;32(6):1078-81. doi: 10.3174/ajnr.A2447. Epub 2011 Apr 14. Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. Miteff F, Faulder KC, Goh AC, Steinfort BS, Sue C, Harrington TJ. 26 consecutive stroke patients treated with solitaire embolectomy device 94% recannalization 56% good clinical outcome mRS 0-2 at 90 days 20% good outcome in basilar occlusions
    •  Solitaire fow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non- inferiority trial – Lancet August 2012  Study designed to show equivalence of newer solitaire device with Merci retriever  55 pts treated with Merci device, 58 with Solitaire  Good clinical outcome at 90 days  Merci 33%, Solitaire 58% Newer Mechanical Devices
    • Newer Mechanical Devices  STAR trial (incl RNSH) ◦ Single arm international multicentre study ◦ Failed IV or IV ineligible, large vessel occlusion ◦ Revascularization 94.7% ◦ ICH 1.5% ◦ Mortality 6.9% ◦ mRS 0-2 at 90 days 57.9%  Ninds ICH 7%, Mortality 21%, Good outcome 39%
    • Intra-arterial Treatment Future  Clearly place for IV and IA treatment  Effectiveness dependent on site of occlusion and time to treatment  Future trial design aimed at ◦ better patient selection, CTA and perfusion ◦ IV ineligible or predicted low success rate ◦ IV ineligible patients  Success in stroke treatment will depend upon correct treatment pathways and protocols for urgent intervention