Interventional Neuroradiology - Hospital Authority · Interventional Neuroradiology a new hope for...

Interventional

Neuroradiology a new hope for stroke patients

Poon Wai Lun, William MBBS (Hons), MRCP(UK), FRCR(UK), FHKCR,

FHKAM (Radiology), MPH (HKU)

Consultant Radiologist Department of Radiology and Imaging

Queen Elizabeth Hospital

Stroke - Epidemiology

The 4th leading cause of death in Hong Kong

Mortality related to Cerebrovascular disease (2012) • 50.5 (male) and 41.7 (female) per 100

000

• > 3200 died of CVA per year!

71% of stroke survivors cannot return to their job

Before the talk… Wait…

What is IA/endovascular treatment for acute ischaemic stroke?

Is it really helpful for our patients?

Can we do it in our HA setting?

Any local results?

Acute Stroke Treatment

IV/IA Thrombolysis or Mechanical thrombectomy are the only hope for patient with acute ischemic stroke

The Goal

• REPERFUSION of SALVAGEABLE ischemic brain tissue as FAST as possible

1.9 million neurons destroyed each minute!!!

Time is Brain Pooled analysis of ATLANTIS, ECASS and NINDS rtPA trials

Favorable outcome (mRS 0-1) at day 90

Adjusted odds ratio with 95 % confidence interval by stroke onset to treatment time

60 90 120 150 180 210 240 270 300 330 360

< 3 h 3-4 h > 4 h

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Stroke onset to treatment time (OTT) [min]

Hacke W et al Lancet (2004)

IV Thromolysis – the Evidence

IV rtPA – the only FDA approved

treatment for acute ischemic stroke with onset <3 hours (level 1, class A)

• NINDS rtPA

• SITS-MOST

Therapeutic window can be extended to 4.5 hours (level B, class I)

• ECASS-3

However…

Small proportion of stroke patients able to receive IV rtPA

• 3.5-10% of stroke patients received IV rtPA

Recanalization rate of ICA and proximal MCA is low after IV rtPA

• 8% - 12%

Xydas et al. Hospital Chronicle 2012

Lee M et al. Stroke. 2010

IA/Endovascular Therapy

Need IA thrombolysis/thrombectomy for patients out of the therapeutic window for IV thrombolysis

• i.e. >3 - 4.5h

May play a role in patients failed IV thrombolysis or having proximal artery occlusion

IA Thrombolysis – the Evidence

PROACT-II (1996 –1998) • 180 patients

• MCA occlusion by angiogram

• IA ProUK + IV heparin vs IV heparin

• Primary outcome – mRS <= 2 at 90D

• Secondary outcomes – NIHSS <=1 at 90D, angio recanalization,

symptomatic ICH, mortality


PROACT-II results

• Median time from onset to IA ProUK

5.3h

• mRS <=2: 40% vs 25% (p=0.043)

• 15% absolute benefit and 58% relative benefit in no. of patients achieved mRS <=2 at 90D

• 7 treated for 1 achieving mRS <=2


PROACT-II results

• Recanalization rate

66% for ProUK vs 18% for control (p<0.001)

• Symptomatic ICH

10% vs 2%

• No excess mortality demonstrated in ITT - 24% ProUK vs 27% control

IA/Endovascular Devices

Mechanical thrombectomy

• Penumbra System

• Solitaire FR revascularization device

• Trevo Stentriever

MERCI Retriever

US assisted thrombolysis

• EKOS MicroLysUS infusion catheter (outdated)

Stentrievers

Solitaire FR

Trevo

Solitaire FR

The Penumbra System

Separator 3D

Summary of the major stroke IA therapy trials

Trial Design Recanalization

Rates

Good Clinical Outcome

(90D mRS<=2)

Mortality sICH

Rx Ctrl Rx Ctrl Rx Ctrl Rx Ctrl

PROACT II RCT, IA proUK+ IV heparin vs IV heparin

66% 18% 40% 25% 25% 27% 10% 2%

MERCI PSA, IA MERCI, IA lytics allowed

60.3%

(48%)

27.7% 43.5%

7.8%

Multi MERCI

PSA, IA MERCI, IA+IV lytics allowed

68%

(55%)

36% 34% 9.8%

Penumbra PSA, IA Penumbra, IA lytics allowed

81.6% 25% 32.8%

11.2%

SWIFT Randomized, Solitaire FR vs Merci

83.3% 48.1% 58.2% 33.3% 17% 38% 2% 11%

Trevo2 Randomized, TrevoPro vs Merci

89.7% 63.3% 55% 40% 33% 24% 6.8% 8.9%

What did the evidence tell us?

Mechanical thrombectomy devices (ie Merci and Penumbra)

• equal or even higher recanalization rate c.f. IA thrombolysis

• Safe – low hemorrhagic complications

However, this does not translate into better clinical outcome…

So, are they useful?

We should be cautious in comparing results between different trials

• Asymmetrical patient populations

• Different mechanical devices

• Different clot locations

• Different clot burden

• Different baseline stroke severity

• Different time to treatment

• Any IV thrombolytics given etc ….

8th Feb 2013 NEJM

Three important RCT on endovascular treatment for acute ischemic stroke published in New England Journal of Medicine on this day

Summary of the major stroke IA therapy trials

Trial Design Recanalization

Rates


(90D mRS<=2)

Mortality sICH


PROACT II RCT, IA proUK+ IV heparin vs IV heparin

66% 18% 40% 25% 25% 27% 10% 2%

IMS III RCT, IA tPA+/-thrombectomy after IV tPA vs IV tPA

65-81%

40.8% 38.7% 19.1%

21.6%

6.2% 5.9%

SYNTHESIS Expansion

RCT, IA tPA or thrombectomy vs IV tPA

30.4% 34.8% 14.4%

9.9%

6% 6%

MR RESCUE RCT, thrombectomy +/- IV tPA vs standard care

67% 14%/

9%

23%/

10%

6% 6-7%

0-3% 0-2%

What do these RCT mean?

IMS III

• endovascular therapy offers no additional benefit in terms of clinical outcome for patients who received IV tPA within 3h of stroke onset

• problem of study: a mixture of IA tPA and old and new generation retrieving devices are used


SYNTHESIS EXPANSION

• endovascular therapy is not superior to IV tPA in terms of clinical outcome when initiated within 4.5h of stroke onset

• problem of study: only 1/3 of patients in the endovascular group received mechanical thrombectomy, others received only IA tPA and microcatheter fragmentation


MR RESCUE

• endovascular therapy is not superior to standard medical care (IV tPA or supportive care) in terms of clinical outcome irrespective the patient has penumbral pattern or nonpenumbral pattern on CT or MR perfusion studies, within 8h of stroke onset

• problem of study: predominantly old generation retrieving devices were used

Results of new RCT pending

SWIFT PRIME trial

• Solitaire FR + IV tPA vs IV tPA

• <6h stroke onset

EXTEND-IA trial

• Solitaire FR + IV tPA vs IV tPA

• Large vessel occlusion, mismatch on perfusion

THERAPY trial

• Pneumbra + IV tPA vs IV tPA

IA Therapy in

HA hospital settings

Workforce

Machines

Consumables

Clinical Pathways

Workforce

Neurointerventionalists

• Interventional Neuroradiologists

• Endovascular Neurosurgeons

• Interventional Neurologists

• Each comprehensive stroke centre need at least 4

Cloft H. Neurosurg Focus 2014

Workforce

Stroke Neurologist

Emergency Physician

Anaesthestist

Rehab Physician

Stroke nurse, Physiotherapist…

Machines

Dedicated machines

• Immediate a/v upon request

CT scanner

• MDCT with brain perfusion capability

Angiography machine

• Biplane

• Flat panel

• Angiographic CT capability

Machines

A&E

CT scan

Stroke

unit

Angio

suit

Consumables

Latest endovascular devices

• Solitaire FR

• Trevo

• Pneumbra

• MindFrame

Clinical Pathway

0h •Onset of acute stroke

? 2h •Pt. arrived at A&E

•Initial assess by EM physician

•Assess by Stroke Neurologist

<3h •Urgent CT brain + CT angio

•Assess by Neurointerventionist

<4h •Start angio + IA therapy

Time after stroke onset

Clinical Pathway – Time is Brain

F/49

Australian tourist

Sudden R sided weakness at 1030

Slurring of speech

NIHSS 8/42


CTA

MTT

CBF

CBV


IV rtPA at 1145 - (1h 15min)

Limb power back to full

Mild residual R CN VII palsy

Discharged on D8 and back to Australia

Illustrative Cases of IA Therapy

Illustrative Case 1 – IA Urokinase

F/58

Living-related donor renal transplant for mesangial proliferative GN 1998

Sudden left sided weakness and slurring of speech

NIHSS 9 at A&E Right internal carotid angiogram


IA thrombolysis started 4h 40min after stroke onset


Post IAT TIMI 3 achieved

NIHSS 0 on D9

mRS 1/5 and Barthel index 100 on D90

Right internal carotid angiogram post-IA UK

Illustrative Case 2 – Solitaire FR

M/39 Chronic smoker

Good past health

GCS 15/15, Dysarthria

Left UL power 0/5, LL power 3/5

Left hemineglect

CT brain: dense right MCA

Right internal carotid angiogram


Solitaire clot removal at 3.5h after stroke onset


To stroke rehab on day 7

Discharged on day 19

Walk unaided

Left UL and LL 4+/5

BI 92/100

Right internal carotid angiogram

after clot removal

Illustrative Case 3 – Penumbra System

F/29 Good PH

Delivered a term baby 1 week ago

Sudden drowsiness, vomiting and aphasia

GCS 11/15

Left hemiplegia

CTA: vertrobasilar thrombosis


Mechanical thrombectomy with Penumbra system started 9h after onset of symptoms

Complete recanalization

Penumbra 054 reperfusion catheter in left VA


Left vertebral angiogram Right vertebral angiogram after thrombolysis


Discharged to rehab on day 10

Mild dysphasia

Taking care of her baby

Illustrative Case 4 – Trevo

F/21

Good past health

Sudden onset of left sided weakness

CT angiogram

• Right MCA occlusion

Failed IV rtPA thrombolysis


Mechanical thrombectomy with Trevo device


Reopening of the right MCA within 30min

Left sided power already regained after transferring back to ward

Further Ix for underlying cause

Local Experience

Retrospective review of patients received IA therapy at QEH and TMH

• TMH: Jun 2004 – Jul 2011

• QEH: Oct 2011 – Apr 2014

N = 38

Age 21 – 83 (mean 63.9)

M : F = 24 : 14

Initial NIHSS = 6 - 22

Local Experience

Site of Arterial Thromboembolism

ICA 2 5.3%

M1 17 44.7%

M2 10 26.3%

M3 2 5.3%

ICA + MCA 4 10.5%

MCA + ACA 1 2.6%

VB 2 5.3%

Local Experience

Mode of IA therapy

IA tPA 21 55.3%

IA tPA + Mechanical 11 28.9%

Mechanical 6 15.8%

Local Experience

Comparison between local data and major stroke trials

N Recanalization

Rates


(90D mRS<=2)

Mortality sICH


Local Data

38 89.5% 58% 7.9% 7.9%

PROACT II

180 66% 18% 40% 25% 25% 27% 10% 2%

Penumbra 125 81.6% 25% 32.8% 11.2%

SWIFT 113 83.3% 48.1% 58.2%

33.3%

17% 38% 2% 11%

Trevo2 130 89.7% 63.3% 55% 40% 33% 24% 6.8% 8.9%

Local Experience

Response time of the IA therapy team (AED door to start of angiogram)

• 13-210min (mean = 118min)

Conclusion

IA therapy for acute ischemic stroke is rapidly developing and promising.

The Multidisciplinary Stroke Teams in various hospitals in Hong Kong are providing FIRST CLASS care for our stroke patients.

Based on VERY LIMITED resources…

Acknowledgement

Neurointervention Team

• YL Cheung

• CM Chan

• WL Poon

• S Lo

Neurosurgery Team

• HM Chiu

• KF Fok

• PH Wong

Neurology Team

• HM Chan

• WC Fong

ICU Team

• KY Lai

A&E

Stroke/IR Nurses & Radiographers

Thank You

Interventional Neuroradiology - Hospital Authority · Interventional Neuroradiology a new hope for...

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