Stroke in India: Disease, systems, and Treatment – Interventional Treatment

1. Stroke in India: Disease, systems,
and Treatment –
Interventional Treatment
Vipul Gupta
Neurointerventional Surgery
Artemis Hospital, Gurgaon

2. MR CLEAN Trial
Netherlands, 2015
ESCAPE Trial
Canadian, 2015
EXTEND-IA Trial
Australian, 2015
SWIFT PRIME Trial
USA, 2015
REVASCAT Trial
Spanish, 2015

3. AHA/ ASA guideline 2015:
Patients should receive endovascular therapy with a stent
retriever if they meet all the following criteria (Class I; Level of
Evidence A). (New recommendation):
 prestroke mRS score 0 to 1
 acute ischemic stroke receiving intravenous r-tPA within 4.5
hours of onset
 causative occlusion of the internal carotid artery or proximal
MCA (M1)
 age ≥18 years
 NIHSS score of ≥6
 ASPECTS of ≥ 6
 treatment can be initiated (groin puncture) within 6 hours of
symptom onset

4. Etiology (Indian scenario)
 Large-artery atherosclerosis – 41%
 Lacunar - 18%
 Cardioembolic - 10%
 Rare – 4%
 Undetermined etiology – 27%
Kaul S, Sunitha P, Suvarna A, Meena AK, Uma M, Reddy JM. Subtypes of
ischemic stroke in a metropolitan city of south India (one year data from
hospital based stroke registry). Neurol India. 2002;50(suppl 1):S8–S14.

5. ICAD
 ICAD incidence - 12% (53/448) amongst ischemic
strokes.
Prevalence (TCD – PSV > 140) – 7% in asymptomatic
but with vascular risk factors
Kate M et al. Imaging and Clinical Predictors of Unfavorable Outcome in Medically
Treated Symptomatic Intracranial Atherosclerotic Disease. J Stroke Cerebrovasc Dis
2014.
Sada S et al. Neurology India. 2014.

6. Indian Experience With
Mechanical Thrombectomy
 STROKE TREATMENT CENTERS:
 Thrombolysis: approx. 100 centers
Number of UAs/Towns and Out Growths(OGs)
Number of UAs/Towns and Out Growths (OGs):
At the Census 2011 there are 7,935 towns in the country. The number of towns has
increased by 2,774 since last Census. Many of these towns are part of UAs and the rest are
independent towns. The total number of Urban agglomerations/Towns, which constitutes
the urban frame, is 6166 in the country.
Type of Towns/UAs/OGs Number of towns
2011
Number of
towns 2001
Towns 7,935 5,161
Statutory Towns 4,041 3,799
Census Towns 3,894 1,362
Urban Agglo. 475 384
Out Growths 981 962
Population 1,336,286,256 (July
2016 est.)
Density 383 people per.sq.km (2011
est.)

7. Total acute stroke: 1096 (March 2002-2006)
 Acute ischemic stroke: 877
 Thrombolysis: 54 (6.1%)

8. Indian Experience With
Mechanical Thrombectomy
Status of Mechanical Thrombectomy
Around 60 centers across country of 1.34 billion.
Among 967 patients enrolled in the on-going Indo-
USA Collaborative National Stroke Registry, 134
patients came within 4.5 hours and 104 (11%)
patients received r-tPA. Intra-arterial and mechanical
thrombolysis was given in 34 (3.5%) patients.

9. Indian Experience With
Mechanical Thrombectomy
Study period: 2009-2013
Total cases: 45

10. Indian Experience With
Mechanical Thrombectomy
STATUS OF MECHANICAL THROMBECTOMY
Public Sector:
AIIMS (New Delhi): 24 cases/Year.
PGIMER (Chandigarh): 18 cases/Year
SCTIMST (Thiruvanthapuram):24-30 cases /Year
NIMHANS (Bangalore): 10-12 cases/year

11. Indian Experience With
Mechanical Thrombectomy
STATUS OF MECHANICAL THROMBECTOMY
• Private Sector:
–New Delhi (single largest center): 26 cases 2015.
–Bangalore (single center): 24 cases 2015.
–Mumbai (two centers): 53 cases 2015

12. 0
50
100
150
200
250
2013 2014 2015
Stent - retriever
Stent - retriever

13. Indian Experience With Mechanical
Thrombectomy
STATUS OF MECHANICAL
THROMBECTOMY
Sale figures:
• Company A: 138.3 devices.
• Company B: 80devices.
• Company C: 45 devices.

14. Challenges ….
 Lack of training programs - guidelines
Insurance
Stroke team
Support from institutions
Private sector – demand driven
Public awareness (medical community)
Timing issue

15. Training challenges
Dedicated training - 2 years vs ….
Disciplines (Radiology, Neurology and
Neurosurgery)
Centers that can train (what nos. ?)
To maintain skill ??
Accreditation board (STNI …)

16. DM Neuroradiology program centers:
• AIIMS
• PGI
• NIMHANS
• SCTIST
University
• SRMC
• KMC
• Vellore
Fellowship program
• Artemis
• Medanta
• MSSH
• KEM Pune
• Mumbai
• Others….

21. Way ahead …
Arrive at an consensus
Start society authorized training
program – based on minimum
requirements
Approach MCI and NBE

22. Challenges ….
Trained neurointerventionists
Infrastructure
Stroke team
Support from institution/hospital
Finance
Public awareness
Timing issue

23. Solutions..
Program viability – aneurysms, AVMs …
Overlap with neurosurgery for aneurysm,
AVMs..
Overlap with neurology for ischaemic
stroke …

24. Round the clock services
INR - Three faculty – two radiology and one from
stroke neurology background . We also provide
emergency services to selected centres
The stroke neurologist INR takes care of all stroke
patients
Overlapping – neurology-stroke-INR team
Based on group practice
One fellow – Stroke-INR fellowship

25. Techs
Encouraged to stay nearby
Training program
Anesthesia and critical care
NI program is part of clinical neurosciences
Active – neurovascular program – SAH
Neuroanesthesia provide cover as for HI etc

26. Financial barrier
Most patients don’t have insurance
They have to be explained in simple clear terms
Major stroke, MVO, we can try to save brain, 70%
recanalization; 50% good outcome at 3-months; risk of
bleed /decompression
Based on written commitment
 Show them pictures
Detailed counseling everyday on written form
Device write off….

27. Promoting stroke intervention program –
awareness
Stroke training program for physicians
Encouraged to take opinions (social media)
Neurology services to selected centers
Public lectures – Rotary, Loin clubs
Stroke week
Media
Testimonials
Learning from cardiologists …

28. •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.

29. 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

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

31. • Parallel Processing, Trust, and Teamwork
• Fast Minimalist Clinical Examination
• Fast, Minimalist Imaging Based on a Decision- Based Paradigm; No
Complex Post Processing of Imaging
• No General Anesthesia
• Use the CT Angiography to Plan the Procedure
• Setting Up the Angiography Room – tech, INR, material

32. Physician Guide – Protocol
based

33. Timing
• Protocol
• Sessions with emergency,
radiology, critical care teams
• Dedicated team – INR
• Monitoring

34. CTMRI
ED

35. Times pre and post implementation of
parallel processing:
Picture to Puncture time:
 PRE Mean: 80 minutes (21 – 260)
 POST Mean: 60 minutes (30 – 140)
(Median – 50 minutes)
Puncture to reperfusion
 POST Median 42 minutes (12 – 120)
DSA next door and direct to suite – P2P –
further 30 minute reduction achieved with a
mean of 3o minutes

36. Our results
Total No. of patients= 42 (M-19, F- 23)
 Time of arrival: 30 min- 840 min (mean 203.8 minutes)
 NIHSS at admission: 5-22 (Mean 14.33)
 MVO 39, IV tPA- 19
Good recanalization (TICI 2b or 3) in 57.1%
mRS 0-2 =52.3%, 3-5 = 34.4%, 6 = 9.5%)
Recanalization V/s Outcome

39. Mechanical thrombectomy in India
• National guidelines
• Training programs – consensus
• Local solutions
• Monitoring of results
• Awareness ….learning from cardiology

40. Thank you ….