mechanical thrombectomy in stroke

1. Presenter:Dr.Abhishek Gupta
Moderator:Dr.Madan Mohan Gupta

2. 64 year old Lady, known case of RHD presented with
altered sensorium and sudden onset of left sided
upper and lower limb weakness 1 hour before
NIHSS-14/42 GCS 15/15 was on presentation ,
Power in LUL 0/5 LLL 0/5
CT ASPECTS Score-10 /10
CT angiography revealed T occlusion of right ICA with
cortical branches filling by leptomeningeal collaterals
INR-1.4 inspite of treatment on Tab.Acitrom
B.Sugar 170
BP 140/100,Spo2-99,HR~80bpm
No H/o Hypertension ,DM

6.  Based on clinical assessment and CT imaging findings,
patient was taken for mechanical thrombectomy
immediately after proper counselling and consent of
the attendants about the benefits and risks of the
procedure.
 Needle to recanalisation time 30 min,TICI GRADE 3
perfusion established
 Post procedure NIHSS 2/42
 Power in LUL and LLL-4/5 on discharge

7. Technique used for Mechanical
Thrombectomy
 The procedure was performed using arterial access
under conscious sedation
 Femoral access was obtained with a 6F long vascular
sheath (Neuro max 088; Penumbra Inc., Alameda, CA,
USA) advanced in the internal carotid artery.
 The Solumbra technique was performed advancing a
stent-retriever (Solitare Covidien, Mansfield, MA,
USA) through the intermediate aspiration catheter
used for ADAPT for the aspiration of the embolus and
TICI grade 3 flow establised

9. Post Procedure assessment

10. Post Procedure CT

11. ADAPT technique

13. Discussion
 Assessing AIS onset time is critical for the determination
of whether a patient can be treated with tPA or
thrombectomy.
 The mismatch between DWI and fluid attenuated
inversion recovery (FLAIR) changes has been proposed
for determination of the time window for potential
intervention but may suffer significant inter or intra-rater
disagreement and subjectivity by comparison to
quantitative
alternatives .
 In adults, DWI appears to reliably predict the core infarct
and the DWI-perfusion weighted imaging (PWI)
mismatch using DSC profiles may then be used to assess
tissue at risk (penumbra)

14. CT ASPECTS SCORE

15.  Based on single-phase CTA raw data and MIP (maximum
intensity projection) images in patients with
unilateral anterior circulation infarct with variable
occlusion involving the MCA with or
without ICA occlusion .
 On a scale of 0 to 3, higher grades are associated with
smaller pretreatment CT perfusion parameters
(MTT, CBF and CBV), final infarct volume, smaller
thrombus extent and improved functional outcomes 2:
 0: absent collateral supply to the occluded MCA territory
 1: collateral supply filling ≤50% but >0% of the occluded
MCA territory
 2: collateral supply filling >50% but <100% of the occluded
MCA territory
 3: 100% collateral supply of the occluded MCA territory

16. The National Institutes of Health Stroke Scale (NIHSS) is a score calculated from 11
components and is used to quantify the severity of strokes
 . The 11 components are:
 level of consciousness (1a: 0-3, 1b: 0-2 and 1c: 0-2)
 best gaze (0-2)
 visual fields (0-3)
 facial palsy (0-3)
 arm motor (0-4)
 leg motor (0-4)
 limb ataxia (0-2)
 sensory (0-2)
 best language (0-3)
 dysarthria (0-2)
 extinction and inattention (0-2)
 These 11 components are then summed and the score correlates with stroke severity.
 0 = no stroke symptoms
 1-4 = minor stroke
 5-15 = moderate stroke
 16-20 = moderate to severe stroke
 21-42 = severe stroke

18.  Thanks