Endovascular Therapy Neuro Intervention (MT) in AIS DR Ganesh

ACUTE ISCHEMIC STROKE-
ENDOVASCULAR THERAPY
Dr Ganeshgouda
Neurologist Nanjappa hospitals
Davanagere
ganeshgoudam4@gmail.com
9380906082
Time is brain
 Ischemic core zone, blood flow less than 10% to 25% of the normal cerebral blood flow
with consequent loss of oxygen and glucose results in rapid depletion of energy stores,
leading to necrosis of neurons and glial cells.
 It is estimated that 1.9 million neurons are lost during each minute of ischemia
Why Endovascular therapy
 Narrow time window with IV tPA
 Contraindications (recent surgery, coagulation abnormalities, and a history of ICH)
 i.v tPA is less effective at opening LVO
 Early recanalization after i.v tPA in only about one third of patients with an occlusion of the internal-
carotid-artery
Extended window
Role in scenarios of
• Factors which predict response in
Slow progressors Extended time window
Wake up stroke
• Core clinical
Unwitnessed stroke mismatch

• Core Penumbra
LVO with minor deficits and then mismatch >1.8,Core<70ml
worsen later • DWI-FLAIR
mismatch
Tissue window
 Concept of “tissue window” v/s time window has proved useful for selecting patients for mechanical
thrombectomy up to 24 hours from symptom onset.
 This concept made development and optimization of endovascular therapies for acute ischemic stroke
 Penumbra -Described as the area of brain tissue that is still viable but is critically hypo perfused and
will progress to infarct in the absence of timely reperfusion
Tissue window
 The duration of the penumbra in humans varies substantially, depending on factors such as
Degree of collateral blood flow supply,
Cerebral perfusion pressure,
Susceptibility of tissue to ischemia and ischemic preconditioning
Location of the vessel occlusion
Factors such as hyperglycemia, body temperature, and oxygen delivery capacity
 INTRA ARTERIAL FIBRINOLYSIS
 MECHANICAL THROMBECTOMY
MECHANICAL THROMBECTOMY
Mechanical Thrombectomy Eligibility–Vessel Imaging
 NIHSS score is the best of the LVO prediction instruments.

 Threshold of ≥10 would provide the optimal balance between sensitivity (73%)
and specificity (74%).
 Threshold of ≥6 would have 87% sensitivity and 52% specificity.
 The sensitivity of CTA and MRA compared with the gold standard of catheter
angiography ranges from 87% to 100%, with CTA having greater accuracy than
MRA.
For patients who meet criteria for MT, noninvasive vessel imaging of the intracranial arteries is
recommended during the initial imaging evaluation
Risk of contrast-induced nephropathy secondary to CTA imaging is relatively low, particularly

in patients without a history of renal impairment
Perfusion imaging
 For patients planned for
endovascular revascularization
presenting after 6 hours of
symptom onset
 3 parameters:
A) Mean transit time.
B) Cerebral blood volume.
C) Cerebral blood flow.
What is NIHSS,ASPECT&MRS SCORE?
INDICATIONS-MT
Class- 1a
Class 2a- Last seen normal 16-24 hours from symptom onset (meeting criteria)
Class 2b- M2,M3 involvement, PCA territory, MRS >1, ASPECT <6, NIHSS <6
Mechanical thrombectomy
 Multiple randomized trials have shown thrombectomy benefit, up to 24 hours after
symptom onset.
 MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND-IA, THRACE,
DAWN, DEFUSE 3 Trials
 Benefit was consistent across age groups
 Patient selection criteria varies based on time
o Within 6 hours and 6-24 hours since last normal, advanced imaging with CT perfusion
or MRI/MR Perfusion is necessary to select patients
 Stent retrievers are preferred devices
FIRST 6
HOURS
FIRST 6
HOURS
TRIALS SHOWING SUPERIORITY OF LATE MT # OVER standard
care
DAWN (DWI or CTP Assessment With Clinical Mismatch in the
Triage of Wake-Up and Late Presenting Strokes Undergoing Neuro
intervention) 6-24 HOURS
Trial included patients at a median of 12.5 hours from onset and showed the largest
effect in functional outcome ever described in any acute stroke treatment trial (35.5% increase
in functional independence)
DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for

Understanding Stroke Evolution 3) 6-16 HOURS
Patients treated with MT at a median of 11 hours after onset had a 28% increase in
functional independence and an additional 20% absolute reduction in death or severe
disability.
Mechanical Thrombectomy: Over 6 hours
Eligibility criteria based upon the DEFUSE 3 trial for patients who can start treatment
(femoral puncture) within 6 to 16 hours
 Deficit on the NIHSS of ≥ 6 points
 Prestroke baseline mRS score ≤2
 Intracranial arterial occlusion of ICA or M1 segment of the MCA
 A target mismatch profile on CT perfusion or MRI defined as an ischemic core
volume <70 ml, a mismatch ratio (penumbra/ischemic core) >1.8, and a mismatch
volume (penumbra-ischemic core) >15 mL
 Age 18 to 90 years
Mechanical Thrombectomy: Over 6 hours
Eligibility criteria based upon DAWN trial for patients who can start treatment
(femoral puncture) within 6 to 24 hours
 NIHSS of ≥10 points
 Prestroke disability: baseline modified Rankin scale (mRS) score ≤1
 Intracranial arterial occlusion of ICA or M1 segment of the MCA
 A clinical-core mismatch according to age:
 NIHSS ≥10 and an infarct volume <21 mL
 NIHSS 10 to 19 and an infarct volume <31 mL
 NIHSS ≥20 and an infarct volume <51 Ml
Normally NIHSS >15 a/w infarct volume of >56ml, 8-13 will have 32 ml and 1-7
will have 8ml infarct volume.
Clinical core mismatch indicates salvageable tissue(penumbra)
MT IN POSTERIOR CIRCULATION STROKE
 BEST- RCT TRAIL comparing MT with standard medical care for patients with
acute vertebra basilar occlusion who could be treated within eight hours
 Was stopped early for slow recruitment and high crossover rate after enrolling 131
patients
 Compared with standard medical care, patients assigned to endovascular therapy had
similar rates of favorable outcome and 90-day mortality by intention-to-treat analysis.
MT IN POSTERIOR CIRCULATION
STROKE
 BASICS trial
300 patients with acute ischemic stroke attributed to basilar artery occlusion, there was no
statistically significant difference in outcomes for endovascular therapy compared with
medical therapy .
However, there was a non significant trend of benefit with endovascular treatment in both
trial.
MT IN POSTERIOR CIRCULATION
STROKE
 BAOCHE trial -Basilar Artery Occlusion Chinese Endovascular was presented at the
European Stroke Organisation Conference2022 on May 6.
 ATTENTION trial- was presented at the same meeting, also showing a benefit of MT in
patients with basilar artery occlusion stroke.
 The two trials, which were both conducted in China, differed slightly in that
ATTENTION recruited patients presenting within 12 hours of stroke onset whereas
BAOCHE enrolled patients in the 6- to 24-hour time window.
 Both trials have shown remarkably similar results, with large increases in the number of
patients achieving favorable functional outcomes when treated with thrombectomy.
Mechanical thrombectomy-Procedure
 Treatment of choice for acute ischemic stroke patients with proximal MCA or
ICA occlusion.
 2 techniques :- a) Stent retriever devices
b) Aspiration devices
SBP between 150
to 180 mmhg
prior to
reperfusion
Can be done
under general
anesthesia or
conscious
sedation
Post procedure
BP <140mmhg
video_2023-10-02_19-26-06.mp4
Limitations of MT
 Only an estimated 10 percent of patients with acute ischemic stroke have a proximal large
artery occlusion in the anterior circulation present early enough to qualify for MT within 6
hours
 9 percent of patients presenting in the 6 to 24 hour time window may qualify for MT
 Only a few stroke centers have sufficient resources and expertise to deliver this therapy
BRIEF ABOUT CAROTID ARTERY STENOSIS
CEA VS CAS
CAS MANAGEMENT
SUMMARY
Conclusion
 Intravenous thrombolysis with i.v tPA – within 4.5hours
 If treatment can be initiated within 6 hours there is no need for additional imaging
like perfusion studies.
 The time window for EVT is 24 hours

References
 Endovascular Treatment of Acute Ischemic Stroke By Gisele S. Silva, MD, MPH, PhD; Raul G.
Nogueira, MD CONTINUUM - 2020; 310–331
 Endovascular Treatment of Acute Ischemic Stroke in Clinical Practice: Analysis of Workflow

and Outcome in a Tertiary Care Center Karin Weissenborn frontiers neurology june 2021
 AHA guidelines –secondary prevention of stroke 2021
 Mechanical thrombectomy for acute ischemic stroke Up To Date
 Bradley and Deroffs neurology in clinical practice 8th edition

 THANK YOU;
ganeshgoudam4@gmail.com
9380906082

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ACUTE ISCHEMIC STROKE-

Why Endovascular therapy

 Narrow time window with IV tPA

 Contraindications (recent surgery, coagulation abnormalities, and a history of ICH)

 i.v tPA is less effective at opening LVO

Unwitnessed stroke mismatch

 INTRA ARTERIAL FIBRINOLYSIS

 NIHSS score is the best of the LVO prediction instruments.

 Threshold of ≥6 would have 87% sensitivity and 52% specificity.

Risk of contrast-induced nephropathy secondary to CTA imaging is relatively low, particularly

DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for

 2 techniques :- a) Stent retriever devices

 The time window for EVT is 24 hours

 Endovascular Treatment of Acute Ischemic Stroke in Clinical Practice: Analysis of Workflow

 AHA guidelines –secondary prevention of stroke 2021

 Mechanical thrombectomy for acute ischemic stroke Up To Date

 Bradley and Deroffs neurology in clinical practice 8th edition

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