Neurointervention in hemorrhagic and ischaemic stroke: recent advances

1. Vipul Gupta
Head, Neurointerventional Surgery
NEUROVASCULAR & STROKE CENTRE
Neurointervention in
hemorrhagic and ischaemic
stroke: recent advances

2. Neurovascular diseases…Stroke….
 Third most common cause of death
 Most common reason for disability
 Appx. 1 in 4 people die within 1 year
 30%–50% do not regain functional
independence
 Annual incidence rate of stroke in India
currently is 145 per 100,000 population
 10 - 15% occur in < 40 years
WHO estimates suggest that by 2050, 80% stroke
cases in the world would occur in low and middle
income countries mainly India and China

3. Neurointerventions…
 SAH- aneurysms, vasospasm
 Intracerebral hemorrhage- AVMs
 TIA- major vessel stenosis E/C & I/C
 Stroke- revascularization
 Diagnosis- Imaging
 Interventional hardware
 Integrated approach

4. Neurointervention Cath
Lab- Biplane flat panel, 3D
imaging, Road map, Dyna
CT
NEUROINTERVENTION EVOLUTION…….
Inbuilt CT..

5. Devices - coils, catheters, balloons, stents

6. Imaging-
understanding

7. ANEURYSMS- basic facts
• Subarachnoid hemorrhage (SAH).
• One in every 20 strokes , at the
prime of ones life (commonly
between 40-50yrs).
• Up to 40-50% patients do not
survive even for a month mostly
because of the rerupture of the
aneurysm
• With proper treatment up to 90%
of patient who reach hospital
before any major damage has
happened will lead an independent
and productive life
Initial CT Scan
Rebleeding after 1 day

8. Clipping vs coiling…
Initially
 Surgically inappropriate
Tremendous changes in last 15-yrs
Cerebral Aneurysms-
• Image-guidance (3-D , Dyna-CT)
• Coil, catheter, balloons, stents
• Drugs- aspirin, clopidogrel, abciximab
• Appx. 90% by endovascular
• Intra-arterial vasospasm mgt.
• HELP and Cerecyte studies – mRS 0-2 in
87% (80% in ISAT)

10. Broad neck aneurysm

11. Balloon assisted coiling

13. ? Near the neck rupture

14. Double balloon technique

15. Stent assisted coiling

17. Dissecting
blister
aneurysm –
poor grade
EVD
2-overlapping Enterprise stents
6-months
follow-up
Blister/
dissecting
aneurysms

18. Very small aneurysms

19. Flow diverters (stents)-

22. 6-months F/U

23. Day 6 Confused, slightly weak on right side
CT perfusion for vasospasm mgt

24. Day 7
Continuous intra-arterial dilatation
Continuous Intra-arterial Dilatation With Nimodipine and Milrinone for Refractory Cerebral Vasospasm.
Anand S, Goel G, Gupta V.
J Neurosurg Anesthesiol. 2013 Jun 14. [Epub ahead of print]

25. ISAT Randomized, prospective,
international trial
 Clipping vs coiling
 9559 patients screened,
2143 randomized
 at 1 year, the difference
in the risk of dependency
or death between the two
groups was 6.9% and the
relative risk reduction was
22.6% (in the coiling
group)
 ISAT follow-up, Lancet 2009- death at 5 years lower
The Barrow Ruptured Aneurysm Trial
Compared clipping vs coiling in SAH patients.
Poor outcome - 33.7% in clipping vs 23.2% in coiling

26.  Guidelines for the Management of Aneurysmal SAH: SpecialWriting
Group of the Stroke Council, ASA/AHA Stroke 2009
 Amenable to both endovascular coiling and neurosurgical
clipping, endovascular coiling can be beneficial (Class I, Level
of Evidence B).
Metanalysis
• Stroke 2013
• AJNR 2013
• Ruptured aneurysms- better outcomes
after endovascular management

27. Our protocol
 Interventionist part of
neurosurgery team
 DSA & if possible
embolization
 Neuro labwith 3D, CT
 NS ICU monitoring
(TCD/CTP).
 Vasospasm- IAVD
 N- 540 (Jan 2014)
Embolization
Surgery
91%
9%
Good outcome
FND
Mortality
Mgt. outcome in good grade patients- 90 % mRS 0-2
(Submitted for publication)

28. CAROTID ARTERY STENOSIS-
20-25% strokes by major vessel stenosis

29. Symptomatic Stenosis
• Non-invasive >70%
• Catheter angiography >50%
• Peri-procedural risk <6%
Asymptomatic Stenosis
• >70% Stenosis
• Periprocedural complication risk is low
• Life expectancy >5 yr
• >80% stenosis- tend to be treated
Revascularization indications-
ASA/AHA guidelines 2011

31. STENTING FOR SEVERE CAROTID STENOSIS

32. Patient with recurrent TIAs…..stenting done the
next day
Should be done as soon as
possible…maximum stroke risk in first few
weeks

33. CAS vs CEA- CREST – NEJM 2011
•2502 patients- Outcome largely same
•More MI in surgery ; more minor strokes in CAS
•Stenting better in 70yrs and less age group
•Nerve palsies not included in end-points
•Less than 1% major stroke
ASA/AHA guidelines 2011-
Endarterectomy and stenting are alternatives
(Class I evidence)
Early intervention is advisable

34. Pivotal randomized trials
Issues-
 Use of embolic protection devices
 Lead in/training phase/experience required
 MI as point of evaluation
 Cranial nerve injuries and local complications

35. Long-term mortality
after peri-
procedural events:
No association with
minor stroke, but
strong association
of MI
Neurological Residual
Deficit Rates by NIHSS
Associated with Minor
Strokes, Equal at 6 months

36. No observed CAS-related
cranial nerve injury (CNI)

37. Treatment protocol at Medanta
 Active endovascular (INR)- 50/year- mostly
symptomatic; Cardiology – 20/year
 Active endarterectomy (CTVS,VS)- 80-90/many
incidental combined with CABG
 We offer both options - thrombus, excessive
tortuosity/kinking, diffuse disease- send to CEA
 “It is not the procedure but expertise matters”

38. Intracranial atherosclerosis
 Intracranial arterial stenosis is responsible for 6% to
10% of ischemic strokes in whites and 22% to 26% of
ischemic strokes in Asians
SAMPRIS Trial- stenting not to be
done as routine in acute stroke
•Recurrent symptom
•Subocclusive stenosis

40. ISCHAEMIC stroke- brain attack
Intravenous
thrombolysis
*Time limitation-
<3-4.5 hrs
• Not effective in large
vessel occlusion
• Many contraindications
 Role of I/A therapy
 Chemical thrombolysis
 Mechanical
recanalization

41. ISCHAEMIC stroke – saving the penumbra

42. Issues with IV tPA
 Time factor (<4.5 hrs)
 C.I. – anti-coagulants, recent surgery, wake-up
strokes….
 <10% eligible
 Large vessel disease
 Time to recanalize

43. •Distal MCA – 44%
•Proximal MCA - 30%
•Terminal ICA - 6%
•Tandem cervical ICA/MCA -27%
•Basilar artery- 30%
Prerecombinant tissue plasminogen activator, National Institutes of
Health Stroke Scale score, systolic blood pressure, glucose, and
Thrombolysis in Brain Ischemia flow grade at the occlusion site were
the negative independent predictors for complete recanalization in the
final model.

44. • 53 studies, 2066 patients
• Sp.- 24%, IV tPA- 46%, IA- 64%, Mechanical- 84%
• Good outcome more in recanalized patients (OR- 4.4)
• Less mortality in recanalized patients

45. CT, CTA, CTP…. – LVO, penumbra
Perfusion imaging
MTTCBF CBV
CBV – 2ml/gm- infarcted core;
CBF, MTT - hyoperfusion area

46. Concept of Penumbra
CBF/MTT CBV
Matched
No penumbra
CBF/MTT
CBV
penumbra
CTA & CTP vs MR DWI & PWI

47. PENUMBRA, 2007MERCI, 2004
STENTREIVERS- SOLITAIRE (2012), TREVO…..

48. •68/M, DM, HTN, CAD, underwent PTCA to
LAD
•Admitted for surgery of aortic
stenosis.
•Double anti-platelets was stopped
•Patient developed acute onset right
side weakness with aphasia.
IV- tPA given, no improvement

50.  Procedure time 28-minutes
 Patient made complete neurological recovery next day

51. Case 2
 41 y.o. male
 Stroke in sleep
 Left sided weakness with facial palsy
 NIHSS 14
 Last well seen at 10:30 PM
 Presented to emergency at 5:08 AM (six and half hours after)

52. 5:14AM

53. 5:23AM

54. 6:22AM
8:07AM

55. Patient made gradual recovery
Left LL 4/5 and UL 3/5
Improved by 30 day follow up

58. 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

59. Mechanical recanalization in acute stroke
 LVO, IV tPA C.I./not -effective
 Stent retrievers – good recanalization; < 1-hr
 Case selection and speed are crucial
 Previous trials failed (older devices, delay, case
selection)
 IMS III – subanalysis- CTA guided cases-
significant benefit
 Many randomized trials going on…..answer in
few years

60. Clinical-
 Bleeding
 Seizures
 Neurological deficit
 Headaches
 Incidental
Cerebral Arteriovenous
malformations

61. AVM- treatment options
 Embolization
 Radiosurgery (GK, LINAC, Cyberknife)- Dr Aditya Gupta
 Surgery – Dr AN Jha, Dr Aditya Gupta
Embolization
Glue (NBCA) vs Onyx embolization

62. Neurosurgery 2006

63. AVMs- multimodality treatment
 Small ruptured- Embo/Sx, RS
 Small unruptured- RS, Embo, Sx
 Large- Embo, RS
 Dural AVFs- Embo
 Spinal AVMs- Embo, Sx

72.  Medanta Stroke & Neurovascular team
 Vascular neurology, Neurointervention,
Neurosurgery, Neurocritical care,Vascular
imaging, rehabilitation
 Stroke
 TIAs (preventive)
 SAH-aneurysms
 ICH
 AVMs

73. Neurointervention
Team at Medanta
•Round the clock
•Integrated team
• Fellowship
•Academics -
Publications

74. STROKE AND NEUROVASCULAR
INTERVENTIONS FOUNDATION
 Newsletter
 Interesting case studies via social media
 Updates regarding treatment protocols
 Stroke training course for physicians
 Advanced stroke and neurointervention
simulator courses
 You tube channel
 Opinion regarding cases via tablets/smart
phones