advance managment of stroke patients..

1. Intra arterial therapy in acute
ischemic stroke
Dr. Bhavin J Patel
DM neurology resident
GMC, Kota

3. Introduction
 Acute ischemic stroke (AIS) is the leading
cause of adult disability and the third
leading cause of death in the United
States, yet until recently it was considered
to be untreatable.

4. Intra arterial therapy
 Intra arterial thrombolysis
 Multimodal approach:- IV+IA thrombolysis
IA thrombolysis + IV GP 2b/3a
antagonist
 Mechanical thrombectomy

5. Evolution of IAT

6. Intra Arterial Thrombolysis

7. IA thrombolysis :- theoretical
advantage
 Higher concentrations delivered to clot
 Gentle mechanical disruption of clot
 Precise imaging of anatomy and
collateral pattern
 Exact degree and timing of
recanalization

9. Intra Arterial thrombolysis

10. Conclusions:- for ant.
circulation
 The lack of recanalization is linked to
poor outcome
 Better rate of recanalizaton: 70% vs
34%
 Likely better outcome than iv tPA
 Larger therapeutic window
 Can be given post operative
 Haemorrhage rate 7 to 10%
 Drawback:- technique, time to
intiation, dose variation

11. Conclusions:- vertebrobasilar
circ.
 No satisfactory studies
 IAT only life saving therapy available
 Benefit in mortality and morbidity after
recanalization
 Upto 24 hr of detoriation or 48 hr of
onset
 Less benefit in coma, quadriparesis
and large infarct pre treatment.

12. Indications
 Persistent occlusion post iv tPa
 Given upto 6 hr
 Contraindication to iv tPA
 Posterior circulation stroke.

13.  Mechanical clot disruption and
extraction
 Stent retriver
Mechnical thrombectomy

14. Mechnical thrombectomy

15. Mechnical thrombectomy

16. video

17. 6 hour of onset

18. Revasca
t
Trial
Thrombectomy reduced
the severity of
poststroke disability
Increased the rate of
functional independence

19.  only rely on imaging parameters ?
Beyond 12 hrs? Possible?

20. 6 to 16 hours
after a patient
was
last known to be
well
endovascular
therapy plus
standard medical
therapy resulted
in better
functional
outcomes than
standard medical
therapy alone

21. known to be well 6 to
24 hours earlier and
who had a mismatch
between clinical
deficit and infarct,
outcomes for
disability at 90 days
were better with
thrombectomy plus
standard care than
with standard care
alone.

22. video

23. Conclusion
 Under the imaging guidance, the
future of acute ischemic treatment is
likely to have longer windows and
multiple treatment modalities used
together:
IV thrombolysis+
IA thrombectomy+
Anticoagulants+
hypothermia+
neuronal protecting agents

24.  Identify patient early
 The earlier, the more option we have
 Using imaging to identify those outside
window
 Identify patient ea
 The earlier, the m
 Using imaging to
the window
 Stronger and bett
be used in evolvin
an even later time

25. Multimodal approach

27. Conclusion:-
 Direct comparison with iv tPA
 Provide flexibility in treatment
 Appropriate selection lead to timely
and rapid reopening of occluded
vessel

28. IV rtPA plus Mechanical
Thrombectomy

29. 2) Should IV be performed
before thrombectomy in LVO
strokes ?
 In favour of IV:-
 Softening thrombus for thrombectomy
(less passes, less cost, shorter
procedure)
 Reperfusion of persisting distal emboli
post thrombectomy !

30. 2) Should IV be performed
before thrombectomy in LVO
strokes ?
 Against IV r-tPA:-
 IV t-PA Cost
 More symptomatic hemorrhages
within/without the infarct
 Increased delay to thrombectomy (drip
and ship +++)
 Proximal thrombus migration

31. Contraindications: IAT
 Intracerebral hemorrhage (lobar,
subdural, intraventicular)
 Subarachnoid hemorrhage
 History of intracerebral hemorrhage
(ICH)
 Cerebral arteriovenous malformation
or giant thrombosed cerebral
aneurysma

32. Contraindications: IAT
 Computed tomographic evidence of
>1/3 middle cerebral artery (MCA)
territory acute infarct or large ischemic
core on perfusion imaging
 Absence of ischemic penumbra
 Uncontrolled hypertension >185/110
mmHg
 Unknown stroke duration

33. Contraindications: IAT
 Thrombocytopenia <100,000
 Bleeding diathesis
 International normalized ratio >1.7 (if
fibrinolysis is planned)
 History of Alzheimer’s disease or
amyloid angiopathy

34. complications
 Distal embolization in a different
territory
 Intramural arterial dissection
 Arterial perforation
 Access-site complications leading to
intervention

35. limitations
 Recanalization efficacy
 Recanalizaton not equated with
reperfusion
 Intracerebral haemorrhage
 Reperfusion injury or cytotoxicity
 No fixed dose or definition of failure for
iv r-tPA.

36.  https://www.youtube.com/watch?v=Kn
JHNNNV0dA
 https://www.youtube.com/watch?v=ajc
gsAr6K2A
 https://www.youtube.com/watch?v=Za
1dFAMiZvU&t=128s
 https://www.youtube.com/watch?v=zl
Q0E29rB3k

37. AHA/ASA Guidelines
2018

38. AHA/ASA Guidelines 2018

39. AHA/ASA Guidelines 2018

40. AHA/ASA Guidelines 2018

42. AHA/ASA Guidelines 2018

43. AHA/ASA Guidelines 2018