What is a Stent
Retriever?:The New Stroke
Guidelines
Tony JosephPGY3
HAEMR
Disclosures….I wish….
OBJECTIVES• What options exist after IV TPA?
• What is IA therapy? What is a stent retriever?
• What's the rush to get the MRA?
• When to transfer for endovascular therapy?
2013
MR RESCUEIMS III
SYNTHESIS
SYNTHESIS• Prospective Randomized Open Blinded End Point
(PROBE)
Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.
SYNTHESIS• PROBE
• TPA eligible with in 4.5hrs
• IA with in 6hrs
• 14% stent retrievers
• mRS 0-1, death at 3 months, sICH at 7 days
Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.
362 patients
NCHCT
IV TPA
IA TPAMechanical Clot
Disruption
Modified Rankin Score
http://www.neuroems.com/2014/06/17/stroke-the-survivor/
SYNTHESIS• PROBE
• TPA eligible with in 4.5hrs
• IA with in 6hrs
• 14% stent retreivers
• mRS 0-1, death at 3 months, sICH at 7 days
Ciccone A, Valvassori L, Nichelatti M, et al; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913.
362 patients
NCHCT
IV TPA
IA TPAMechanical Clot
Disruption
IMS III• Prospective Randomized Open Blinded End Point
(PROBE)
IMS III• PROBE• NIHSS ≥ 10• Sx onset w/ in 5hrs
• 1.5% stent retrievers
• mRS 0-2, death at 90 days
656 patients
IV TPA with in 3 hours
CT
IV TPA
onlylow dose TPA
and/orIA TPA/DeviceBroderick JP, Palesch YY, Demchuk AM, et al; Interventional Management of
Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke.
N Engl J Med. 2013;368(10):893-903.
IMS III• PROBE• NIHSS ≥ 10• CTA added on
later• 1.5% stent
retrievers• mRS 0-2, death
at 90 days
656 patients
IV TPA with in 3 hours
CT
IV TPA only low dose TPAand/or
IA TPA/Device
MR RESCUE• Prospective Randomized Open Blinded End Point
(PROBE)
MR RESCUE• PROBE
• 118 patients
• CT/MRI
• large artery stroke with favorable penumbra
• MERCI / PENUMBRA
• optional IA TPA
Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914-923.
MR RESCUE• PROBE
• 118 patients
• CT/MRI
• large artery stroke with favorable penumbra
• MERCI / PENUMBRA (wine cork screw)
• optional IA TPA
Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914-923.
2015
MR CLEANESCAPE
SWIFT PRIME REVASCAT
EXTEND IA
MR CLEAN• PROBE
• 500 patients
• NIHSS ≥ 2
• Proximal anterior circulation stroke w/ in 6 hrs
• CTA/MRA/DSA
• mRS score 0-2 improved significantly
• 81% stent retrievers
Usual Care
Usual Care+
IA TPA and/ormechanical thrombectomy
STENT RETRIEVERS
http://directorsblog.nih.gov/2015/03/10/clot-removal-impressive-results-for-stent-retrievers-in-acute-stroke/
http://directorsblog.nih.gov/2015/03/10/clot-removal-impressive-results-for-stent-retrievers-in-acute-stroke/
https://www.strykerneurovascular.com/products/ais/trevo-xp-provue-retriever-4x20mm
ESCAPE
ESCAPE• PROBE
• 316 patients
• NIHSS > 5
• CTA
• randomized up to 12 hours after sx onset
• 86% stent retrievers
IV TPA with in 4.5 hours
IV TPA + endovascular tx (stent retrievers)
http://thehappyhospitalist.blogspot.com/2012/11/Should-I-Become-An-ICU-Nurse-someecard-Humor-Explains-Why.html
MR CLEANESCAPE
SWIFT PRIME REVASCAT
EXTEND IA
SWIFT PRIME
SWIFT PRIME
IV TPA with in
4.5 hours
IV TPA + endovascular tx (stent retrievers)
196 patients
NIHSS 8-29
CTA or MRA w/ ICA or M1 occlusion
• 100% of both groups got TPA
• 89% stent retrievers
MR CLEANESCAPESWIFT PRIME REVASCAT
EXTEND IA
EXTEND IA
EXTEND IA• PROBE
• 70 pts
• CT or MR
• Perfusion studies required
• ICA, M1, or M2 occlusion visualized
• 100% of both groups got TPA
EXTEND IA• IV TPA vs. IV TPA + stent retriever
• groin puncture with in 6hrs and complete by 8hrs
• Outcome was reperfusion at 24 hrs AND
• mRS 0-1 at day 3
• 8pt reduction in NIHSS
• no sICH difference
MR CLEANESCAPESWIFT PRIME REVASCAT
EXTEND IA
REVASCAT
REVASCAT
IV TPA
IV TPA + thrombectomy with stent retriever
• mRS 0-2 at 90 days improved
• no sICH difference
206 pts up to age 85
NIHSS ≥ 6
ICA or M1 occlusion
No improvement after 30 minutes of TPA
MR CLEANESCAPESWIFT PRIME REVASCAT
EXTEND IA
MR CLEANESCAPESWIFT PRIME REVASCAT
EXTEND IA
Badhiwala, J H. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA: Journal Of The American Medical Association Volume: 314 Issue: 17 (2015-11-03) p. 1832-1843. ISSN: 0098-7484
More trials to come…
• THERAPY• THRACE• DAWN• POSITIVE
The NNT
Class 1; Level A Evidence
•Give the IV TPA•Then get a CTA (or MRA)•Refer to endovascular therapy if (rule of 6)•18 years or older (duh!)•prestroke mRS 0 or 1•got TPA with in 4.5 hours• ICA or M1 occlusion (no M2)•NIHSS at least 6•ASPECTS at least 6•groin puncture with in 6 hours
•Stent retrievers preferred over MERCI
ASPECTS?• Alberta Stroke
Programe Early CT Score
• 10 is normal NCHCT
• lose points for involvement of MCA territory
• Score 8-10 likely to benefit from TPA
• Score of 7 or less is bad
Class IIA; Level C
• If TPA contraindicated, may consider endovascular with stent retriever
Class IIB; Level C
• After 6 hours, it’s a gamble to do endovascular
• longer time trials pending
• Advanced imaging (perfusion) benefits beyond CTA/MRA are unknown
Class IIB; Level C
• Forget the studies and go anywhere M2, M3, ACA, vertebral, basilar, or posterior cerebral arteries
• if sx within 6 hours
• Go nuts on kids too
Class IIB; Level B-R
• If they have clot at ICA or M1 clot but fit none of the rule of 6 except for time, go nuts
Class III; Level B-R
• Do not wait for the TPA to work, like REVASCAT trial did, got straight to endovascular therapy
What about IA TPA?
• r-TPA is not FDA approved for this
• Doseage?
• Use for carefully selected pts (Class I; Level B-R)
• even if iv r-TPA is contraindicated (Class IIB; Level C)
• Use a stent retriever instead (Class I; Level E)
EMS System• Acute Stroke Ready Hospitals
(ASRH)
• Primary Stroke Center (PSC)
• Comprehensive Stroke Center (CSC)
• Primary centers should consider getting a CTA/MRA to decide on transferring Class IIB; Level C
http://www.jointcommission.org/assets/1/18/StrokeProgramGrid_abbr_AHA-TJC_5-1-15.pdf
Rare Events
• 4% of patients receive TPA
• Less than 1% receive endovascular therapy
Adeoye O, Albright KC, Carr BG, et al. Geographic access to acute stroke care in the United States. Stroke. 2014;45(10):3019–3024.
CASE TIME• DC is a 60yoM who
presents with left sided weakness, symptom onset 40 minutes ago, NIHSS 8, CT and CTA show M1 occlusion. Should we give TPA?
• Should we recommend thrombectomy with a stent retriever?
DS is 64yoM p/w NIHSS 10Sx started 3 hours agoCT w/ ASPECTS 8TPA GivenNearest CSC is 4 hours away. Do you…
A. Get CTAB. Transfer DSC. Wait for the TPA to
workD. Admit to the ICU
• DD is a 65yoM who presents with weakness that started 4 hours ago and NIHSS 7, CT neg for hemorrhage.
• TPA?
• CTA shows M3 stroke, endovascular therapy referral?
Special thanks to help from….
Dr. Raghu Seethala
Dr. Joshua Goldstein
Dr. Thabele Leslie-Mazwi
Stroke Models Physicians (DC, DS, DD)
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