A sixty five year old female presented at five hours after symptom onset with a NIHSS score of 22. Imaging showed a right middle cerebral artery occlusion. The patient underwent mechanical thrombectomy using a stent retriever. Follow up imaging showed reperfusion of the previously occluded vessel and the patient was discharged with mild residual aphasia and a modified Rankin score of 2. Factors such as rapid triage protocols, minimizing delays from imaging to treatment, and standardized approaches can help reduce time to recanalization and improve outcomes in acute ischemic stroke.

1. Stroke EVT
Panel discussion

2. 26 female wake up stroke; NIHSS 22; R sided weakness and aphasia

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

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

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

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

7. Issues
• Trials
• Simplicity
• Change of techniques
• Cost issues
• One standard technique

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

9. F/U MRI; Some residual mild aphasia

10. Technique
• Simple – similar result in
different hands and at all times
• Fast – stick to one technique
• Each step as a protocol –
everybody in team in sync
• Avoid experimentation in initial
phase
• Other factors (selection, time …)
more important

11. Device – technique
Comparison of protocol- Randomised (Intervention Vs
Standard medical therapy)

12. TREVO, Stryker Neurovascular
REVIVE, Codman
Neurovascular
ERIC, Microvention
Technique ……

13. Choice of Stent retriever and why ?
A. Solitaire
B. Trevo
C. Revive
D. ERIC
E. Other

14. 14
Presentation Title (Edit on Slide Master) |
June 1, 2015 | Confidential, for Internal
Use Only
SOLITAIRE 2 - IMPROVED TENSILE STRENGTH
Solitaire™ 2 Device
Solitaire™ FR Device
The Solitaire™ 2 Revascularization Device also employs a
redesigned attachment zone offering a 2x improvement in
joint strength designed to eliminate unintended
detachments
0
2
4
6
8
10
12
14
Peak Load
Solitaire™ FR Device
Solitaire™ 2 Device
(
N
)

15. 15
Presentation Title (Edit on Slide Master) |
June 1, 2015 | Confidential, for Internal
Use Only
SOLITAIRE 2 Device overview
Reference
Number
Recommended
Vessel
Diameter (mm)
(A) Total
Length (mm)
(B) Retrieval
Zone (mm)
(C) Device
Diameter
(mm)
(D) Push Wire
Length (cm)
(E) Distal
Markers
(F) Proximal
Markers
Distance
from Distal
Tip to
Flourosafe
Marker (cm)
Micro
Catheter ID
(in)
SFR2-4-15 2.0 - 4.0 26 15 4 180 3 1 <130 .021
SFR2-4-20 2.0 - 4.0 31 20 4 180 3 1 <130 .021
SFR2-4-40 2.0 - 4.0 50 40 4 180 3 1 <130 .021
SFR2-6-20 3.0 - 5.5 31 20 6 180 4 1 <130 .027
SFR2-6-30 3.0 - 5.5 42 30 6 180 4 1 <130 .027

16. Trevo and Trevo XP
High
Integration
Radial Force
Large Cell
Size with
Low
Coverage
Tubular
Design
INTEGRATE & PULL
Photograph taken by Stryker Neurovascular.

17. Solitaire™ FR Device vs. Trevo™* Device
Design Overview
**Competitive Testing Report FD2815.
***Covidien Testing Data: FD2601A
Trevo™* Device
Solitaire™ DeviceImages property of Covidien. Image is an artistic rendering
and not a n exact depiction of the Solitaire™ FR Device.
Image property of Covidien. Image is an artistic
rendering and not a n exact depiction of the Trevo™
Device.
• The Solitaire™ FR device - Parametric™ design that may
provide multiple planes of clot contact.
•Trevo - straight cut tube ; struts of the Trevo™* device to cut
into the clot
Consistent
Cell Size
Variable Cell
Size
Force-
Flex™
Straight-
Cut

18. 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

19. 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

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

23. 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 (??)

24. 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

25. • 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)

26. • 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

28. 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

29. 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

30. • 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.

33. 2 months later

34. 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

38. Stenting
Still occluded

40. Patient presented with in 2 hours
Futile IV tpa
62/F, 3-hours, NIHSS 18

41. Imaging
A. CT, CTA
B. CT, CTA, collateral scoring
C. CT, CTA, CTP
D. MR – DWI, MRA
E. MR – DWI, MRP, MRA
F. CT, CTA, MR- DWI

42. Patient presented with in 2 hours
Futile IV tpa

43. 26 female wake up stroke; NIHSS 22; R sided weakness and aphasia

44. Good collaterals by the Miteff method (OR, 3.341; 95% CI,
1.203–5.099; P .014) was the independent predictor of good
outcome amongst various collateral grading scales.
Arterial Collateral status –
penumbra, retention of
penumbra

45. Miteff system
A, Contrast opacification all sylvian branches.
B, Some vessels can be seen at the Sylvian fissure.
C, distal cortical filling alone

46. Modified Tan system. A, Less than 50% of the MCA territory. B, More than 50%
of the MCA territory

47. Multiphase CTA
Better able to predict outcomes than single phase and perfusion CT

50. CT, CTA, CTP….
CT perfusion imaging
MTTCBF CBV
Quantitative CTP mismatch classification using relCBF and Tmax is similar to perfusion-diffusion MRI.
Stroke. 2012 Oct;43(10):2648-53. Epub 2012 Aug 2.
Incremental improvement in interobserver reliability was demonstrated for
NCCT, CTA-SI, and CTP-CBV, respectively. (Stroke. 2013;44(1):234-6) 25.

51. CT perfusion
•
J Neurol Neurosurg Psychiatry. 2013 Jan 25.
CT perfusion improves diagnostic accuracy and confidence in acute ischaemic
stroke.
CTP was more frequently diagnostic than NCCT (80% vs 50%, p<0.001).
Normal CTP in 86/87 patients with stroke mimics supported withholding tPA
Consideration of multiple available CT sequences increases confidence for
correct stroke diagnosis among inexperienced readers and may facilitate
identification of stroke mimics
Stroke. 2013 Feb 12. [Epub ahead of print]
Computed Tomography Workup of Patients Suspected of Acute Ischemic Stroke:
Perfusion Computed Tomography Adds Value Compared With Clinical Evaluation,
Noncontrast Computed Tomography, and Computed Tomography Angiogram in
Terms of Predicting Outcome.
Zhu G, Michel P, Aghaebrahim A, Patrie JT, Xin W, Eskandari A, Zhang W, Wintermark M.
J Neurointerv Surg. 2012 Nov 26. [Epub ahead of print]
CT perfusion-guided patient selection for endovascular recanalization in acute
ischemic stroke: a multicenter study

52. Beating the Bullet!!!!

53. •The Interventional
Management of Stroke pilot
trials tested combined IV/IA
therapy onset.
•Among the 54 cases, only time to angiographic reperfusion and age independently
predicted good clinical outcome after angiographic reperfusion.

54. 30-min delay in angiographic reperfusion reduced the relative
likelihood of a good clinical outcome by 12% i adjusted analysis.

55. What did ESCAPE trial aim for?
P2P- picture to puncture
P2R – picture to recanalization
A. P2P - 90 min, P2R - 120 min
B. P2P - 60 min, P2R – 120 min
C. P2P - 60 min, P2R – 90 min
D. P2P – 45 min, P2R – 60 min
E. P2P – 30 min, P2R – 60 min

57. TIME for recanalization
• Onset to door time
• Door to Imaging/picture
• Picture to puncture (P2P)
• Puncture to recanalization time
Hospital processes
Technical skills
• Onset to puncture/groin time
• Onset to recanalization time
• Door to Puncture (D2P)
• Picture to recanalization (P2R)
Society infrastructure
Ultimate predictor

59. One hundred forty-six patients
(93 pre- vs. 51 post-QI) were analyzed.

60. The worst clinical outcomes were noted with door-to-puncture
times of 136 minutes or greater
( J Am Heart Assoc. 2014;3:e000859
N=478

61. P2P Challenges
• CT vs MRI
• Availability of the angiosuite SOS
• 24x 7 neurointerventionist, anaesthetist, technician, nurse
• Team of like minded people
• Overcoming the Financial Barrier

62.  Rapid Triage Protocol and Stroke Team Notification
 Single Call Activation System
Changes at Medanta

63. Door time recording by CCTV footage
Transfer Directly to CT
Rapid Acquisition and Interpretation of Brain Imaging
Multimodal imaging protocol (CTA/CTP)
Parallel approach
Clinical assessment ‘en route’ to Imaging.
Access line and blood investigations (POC)
Prepare IV tPA
Alert Angio suite/ Lab personnel
Financial considerations/ undertaking
Consent – pre written
Changes at Medanta

64. Puncture to Recanlization time
• Planning on CT angiography
• Local anaesthesia
• No groin preparation
• Putting Foley’s after deploying stent
• Standardized stroke kit that is ready to go
(Stroke. 2014;45:e252-e256.)

65. Tips to getting the clot on first pass
• Use of balloon guide catheter
• Long stent 4mm X 40 mm solitaire
• Push & Fluff technique
• Prayer!!!

66. • 41 year old male, Severe MR, EF 20%
• Stroke in sleep, NIHSS 14 on admission

67. 6:22AM

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

69. For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
URL:
www.sanif.co.in
Facebook:
https://www.facebook.com/strokeawarenessindia
https://www.facebook.com/vipul.gupta.35175
Twitter
https://twitter.com/drvipulgupta25
LinkedIN
https://in.linkedin.com/pub/dr-vipul-gupta/51/8a1/25a
YouTube
Channel: Stroke & Neurovascular Interventions
www.youtube.com/c/StrokeNeurovascularInterventionsfoundation
Dr Vipul Gupta

70. Thank You