This document summarizes a panel discussion on endovascular stroke treatment techniques. It discusses various stent retriever devices for clot removal, such as Solitaire and Trevo. It also discusses direct aspiration techniques like ADAPT and ARTS (SOLUMBRA). The document then reviews case examples of endovascular procedures including recanalization times. It discusses considerations for antiplatelet protocols after stenting and issues around emergency carotid stenting. Overall, the document provides an overview of different endovascular stroke treatment options and techniques.

1. Stroke EVT
Panel discussion

2. Solitaire (ev3)- 2012, Trevo (Stryker), Revive™ SE (Codman),
Etc…. etc…..
Stentretrievers - Stent or stent-like system for
clot removal

3. ARTS (SOLUMBRA)
(Aspiration-Retriever Technique for Stroke)

4. Techniques..
ADAPT…
A Direct Aspiration First
Pass technique

5. Techniques
A. Stent retriever
B. Stent retriever with BCG
C. Stent retriever with DAC (ARTS), SOLUMBRA
D. ADAPT
E. Other

6. P to P – 58 minutes
Puncture to
reperfusion – 18
minutes

7. • 60 years old female.
• h/o hypertension and hypothyroidism
• Acute onset left hemiparesis and left facial weakness
• No history of LOC/seizures
• CT Brain , perfusion and angio done 6 1/2 hours after ictus.

8. Tandem – Proximal ICA occlusion (AS)
with MCA clot
A. Distal followed by proximal PTA/Stent
B. Proximal PTA followed by distal
C. Proximal stent followed by distal
D. Proximal suction followed by distal
E. Distal with no proximal intervention

11. 2 months later

12. A
D
A
C
B
A
E F
HG
A sixty five year old presented at five hours of
symptom onset with a NIHSS of 22

14. Anterograde vs retrograde approach:
Antegrade : Stenting first
Pros:
Access to distal lesion
Perfusion through collateral (in case of tandem MCA occlusion)
Reduced risk of repeat embolism (??)
Cons: Delay in reperfusion of occluded territory
Retrograde: Thrombectomy first
Pros: Early reperfusion of occluded territory
Cons: Access to distal lesion is limited
Risk of repeat embolism (??)

15. Our approach
Acute stroke with ICA occlusion
• Usually distal first , take the guiding catheter across
the stenosis
• Terumo/microcatheter to cross
• DAC/Neuron 6F - aspiration
• Co-axial approach
• Recanalize the I/C part
• Check the proximal ICA (wire in situ)
• If good flow , not a severe stenosis - wait
• Usually needs Angioplasty/stenting
• Drugs – If IV tPA given – Ecospirin 150 mg,
Clopidogrel 225 mg ; other wise 300, 450 mg

16. • 28 patients
• Antegrade approach (85.7%); Reverse approach (14.3%)
• Antiplatelet: Load Aspirin (650 mg) when stenting anticipated.
• Cone-beam CT after tt - No hmg, 600 mg loading dose of clopidogrel.
SICH in 2 (one received IV tPA)

17. • Retrospective; September 2010 and April 2013
• Compared proximal vs distal approach
• Weight-adapted bolus of tirofiban followed by a continuous infusion
for 24 h to prevent in-stent thrombosis
• After exclusion of cerebral hemorrhage on follow-up imaging, 500 mg
of acetylsalicylacid (ASA) and 300 mg of clopidogrel

19. Issues with Stenting in the acute setting: Factors to
be considered.
• Infarct core volume
• Time to reperfusion
• Received IV tPA or not
• Antiplatelet to be tailored to above
• Need for Abciximab in case of in-stent thrombosis
(increases bleeding risk)
• Risk of stent occlusion
• Antiplatelet protocol: Thrombolysis (Yes) – Ecosprin (300);
CT Brain in 12 to 24 hours no hemorrhage add Clopidogrel.
• Thrombolysis (no) – Ecosprin 300 and Clopidogrel 600
loading

20. Emergency carotid stent –
drug protocol
A. Loading with abciximab or equivalent
B. Loading with aspirin and clopidogrel
C. CT followed by loading
D. Single anti-platelet followed by second after a while
E. Other

21. 64 year old man with left hemiparesis, bought to emergency in 60 min, NIHSS 1
No improvement after IV tpa
54, M, 2 hours, NIHSS - 17

24. Follow up
Patient
Improved
mRs 2 at
discharge
 CTA 15 days later show
occluded stent
 Right MCA opacifies through
Acom

27. Stenting
Still occluded

29. • 41 year old male, Severe MR, EF 20%
• Stroke in sleep, NIHSS 14 on admission

30. 6:22AM

31. Patient made gradual recovery
Left LL 4/5 and UL 3/5 - 30 day follow up
mRS at 90 days- 0

32. • 46-year old male,
hypertensive, irregular
treatment
• Presented with sudden
onset right UL and LL
weakness 3 days before
hospital admission,
weakness improved
spontaneously without
treatment

35. ICA dissection - Choices …
• A – Anti-platelet/anti-
coagulant
• B – Stents
• C- Bypass
• D – HHH
• E – PVO

36. • Patient again developed weakness 1 day
before hospital admission
• Weakness was fluctuating in nature,
deteriorating in standing position or walking
• Improvemnt in lying down position
• Repeat imaging – no significant change
• Choices ??

39. Balloon
mounted
stent

40. Carotid wall
stent
Balloon
mounted
stent

41. • Patient is
neurologically
stable, Power
5/5 in both UL
and LL, no
aphasia
• On dual
Antiplatelets

42. • Carotid dissections –
• Most do well on anti-
platelets/anti-coagulant
• Selected cases – with worsening
or repeated strokes on medical
therapy – stent assisted
reconstruction
• May have to cross petrous bend
– coronary/self expanding

43. CTA
Cerebral
Angiogra
First Stent
placemen
Second
stent
Stents

44. • 56 years old male
• Known smoker and hypertensive , on irregular
medication
• P/w wake up stroke, reached hospital at 8 am,
1 hour after detection of symptoms
• BP-160/80 mm hg
• Clinically Right hemiplegia with global aphasia
• NIHSS- 16

45. • Decision of
endovascular treatment
was taken based on CTA
and MRI DWI findngs

46. • Solitaire was used.
• Done under local anaesthesia

48. • Failure to
recanalise
with
development
of dissection
• 2nd attempt -
failed

49. Choices ??
• A – Try Soliatire and abandon
• B – Take guiding beyond spasm/dissection and
soliatire
• C – ADAPT
• D – Solumbra
• E – Try Trevo

50. • 3 rd attempt with solitaire – failed ; decision
for Solumbra

54. • However, meanwhile patient has a episode of
vomiting and developed aspiration, hence he
was intubated and kept on ventilator
• Dissection was managed conservatively
• Patient was extubated after 24 hours
NCCT D1 D2

55. • Patient continued to improve during hospital stay
• On Day 3 patient was able to walk with support and
comprehension improved
CT Angio D7

56. • Patient was discharged and advised to follow
up
• Cardiac evaluation including 2 D echo, TEE,
Holter were negative
• Patient refused for long term cardiac
monitoring
• On follow visit after 2 weeks, patient
improved dramatically, Power in right LL 5/5,
right UL 4+/5 with mild broca’s aphasia

57. For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
URL:
www.sanif.co.in
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Dr Vipul Gupta

58. Thank you ….
STROKE – MASTERCLASS
September 30th-Oct 1st ; Artemis Hospital
Medical, IV tPA,Mechanical thrombectomy, TCD, Imaging , Botox