Neurointervention in hemorrhagic and ischaemic stroke
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Transcript of Neurointervention in hemorrhagic and ischaemic stroke
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Vipul Gupta
Head, Neurointerventional Surgery NEUROVASCULAR & STROKE CENTRE
Neurointervention in hemorrhagic and ischaemicstroke: recent advances
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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
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Neurointerventions…
SAH- aneurysms, vasospasm
Intracerebral hemorrhage- AVMs
TIA- major vessel stenosis E/C & I/C
Stroke- revascularization
Diagnosis- Imaging
Interventional hardware
Integrated approach
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Neurointervention Cath
Lab- Biplane flat panel, 3D
imaging, Road map, Dyna
CT
NEUROINTERVENTION EVOLUTION…….
Inbuilt CT..
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Devices - coils, catheters, balloons, stents
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Imaging-
understanding
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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
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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)
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Broad neck aneurysm
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Balloon assisted coiling
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? Near the neck rupture
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Double balloon technique
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Stent assisted coiling
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Dissecting
blister
aneurysm –
poor grade
EVD
2-overlapping Enterprise stents 6-months
follow-up
Blister/
dissecting
aneurysms
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Very small aneurysms
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Flow diverters (stents)-
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6-months F/U
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Day 6 Confused, slightly weak on right side
CT perfusion for vasospasm mgt
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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]
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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
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Guidelines for the Management of Aneurysmal SAH: Special Writing 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
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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)
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CAROTID ARTERY STENOSIS-
20-25% strokes by major vessel stenosis
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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
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STENTING FOR SEVERE CAROTID STENOSIS
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Patient with recurrent TIAs…..stenting done the
next day
Should be done as soon as
possible…maximum stroke risk in first few
weeks
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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
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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
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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
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No observed CAS-relatedcranial nerve injury (CNI)
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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”
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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
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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
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ISCHAEMIC stroke – saving the penumbra
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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
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•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.
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• 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
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CT, CTA, CTP…. – LVO, penumbra
Perfusion imaging
MTTCBF CBV
CBV – 2ml/gm- infarcted core;
CBF, MTT - hyoperfusion area
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Concept of Penumbra
CBF/MTT CBVMatched
No penumbra
CBF/MTTCBV
penumbra
CTA & CTP vs MR DWI & PWI
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PENUMBRA, 2007MERCI, 2004
STENTREIVERS- SOLITAIRE (2012), TREVO…..
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•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
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Procedure time 28-minutes
Patient made complete neurological recovery next day
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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)
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5:14AM
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5:23AM
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6:22AM
8:07AM
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Patient made gradual recovery
Left LL 4/5 and UL 3/5
Improved by 30 day follow up
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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
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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
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Clinical-
Bleeding
Seizures
Neurological deficit
Headaches
Incidental
Cerebral Arteriovenousmalformations
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AVM- treatment options
Embolization
Radiosurgery (GK, LINAC, Cyberknife)- Dr Aditya Gupta
Surgery – Dr AN Jha, Dr Aditya Gupta
EmbolizationGlue (NBCA) vs Onyx embolization
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Neurosurgery 2006
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AVMs- multimodality treatment
Small ruptured- Embo/Sx, RS
Small unruptured- RS, Embo, Sx
Large- Embo, RS
Dural AVFs- Embo
Spinal AVMs- Embo, Sx
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Medanta Stroke & Neurovascular team
Vascular neurology, Neurointervention, Neurosurgery, Neurocritical care, Vascular imaging, rehabilitation
Stroke
TIAs (preventive)
SAH-aneurysms
ICH
AVMs
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NeurointerventionTeam at Medanta
•Round the clock
•Integrated team
• Fellowship
•Academics -
Publications
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