4/4/2019 Acute Stroke Interventions: Indications, Access, & Outcomes Daniel Cooke Assc. Prof. Dept. of Radiology UCSF Director NIR ZSFG UCSF Vascular Symposium Thursday, April 4 3:45-4:05pm 1 Disclosures • None 2 1
4/4/2019 The Message • Time is brain. – The interval from symptom onset to reperfusion is the most significant modifiable variable in predicting clinical outcome. 3 Outline • Background • Evidence – Time – Physiology • Workflow – Direct-to-Angio – Anesthesia – Access 4 2
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4/4/2019 15 AIS • Epidemiology – 800K/year US • 5 th leading cause mortality • Leading cause morbidity • Natural History Large Vessel Occlusion – ~15% of all ischemic stroke – Resistant to IV r-tPA with low rates of early recanalization • distal ICA 4.4%, • M1MCA 32.3%, • M2-MCA 30.8%, • basilar 4% Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, Watson T, Goyal M, Demchuk AM. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010 Oct;41(10):2254-8 16 8
4/4/2019 CT ASPECTS http://www.aspectsinstroke.com 17 Trials Summary Grotta J and Hacke W. Stroke Neurologists Perspective on the New Endovascular Trials. Stroke June 2015. 18 9
4/4/2019 Time “drip and ship” Grotta J and Hacke W. Stroke Neurologists Perspective on the New Endovascular Trials. Stroke June 2015. 19 HERMES The Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration 20 10
4/4/2019 HERMES • Pooled patient data from 5 RCTs – 1287 patients – Pre-specified outcomes • Sub group analysis Saver JL, et al ; HERMES Collaborators.. Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA. 2016 Sep 27;316(12):1279-88. Goyal M, et al.. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr 23;387(10029):1723-31 21 HERMES • 2.6 NNTT for 1 point mRS improvement at 90 days 22 11
4/4/2019 HERMES 23 HERMES 24 12
4/4/2019 Time • 6% decrease in absolute risk difference in good outcome (mRS < 3) for every hour delay in reperfusion 25 AHA/ASA 2015 Guidelines 26 13
4/4/2019 Physiology • Beyond 6 hours • Unknown LSN 27 28 14
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4/4/2019 Time vs. Physiology • DAWN (n = 206) – Intervention vs. Medical 6 – 24 hours LSN • Stopped early (2.28.17) – 90 day mRS < 3: 48.6% vs. 13.1% • NNT 2.8 Nogueira RG, et al. DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018 Jan 4;378(1):11-21c 31 Time vs. Physiology • DEFUSE 3 (n = 182) – Intervention vs. Medical 6 – 16 hours LSN – < 70 ml (core) AND > 1.8 penumbra:core – 90 day mRS < 3: 41% vs. 11.5% Albers GW et al. DEFUSE 3 Investigators. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018 Jan 24 32 16
4/4/2019 AHA/ASA 2018 Guidelines 33 AHA/ASA 2018 Guidelines 34 17
4/4/2019 Beyond RCTs • Core infarct (CBF): “too sick” Campbell et al. The Lancet Neurology, 2019 35 Beyond RCTs • Core infarct (CBF): “too sick” Campbell et al. The Lancet Neurology, 2019 36 18
4/4/2019 Beyond RCTs • Clinical presentation (NIHSS < 6): “too well” – Sarraj et al. • 90 MM vs. 124 EVT • 67% vs. 63% mRS 0-2 @ 90 days • 0% vs. 6% SICH Sarraj et al. Stroke, 2018 37 WORKFLOW: MAKING TIME 38 19
4/4/2019 Workflow Bourcier et al. JAMA Neurology. 2019 39 40 20
4/4/2019 Workflow • Direct-to-angio – Psychogios et al. • 44 (MDCT) vs. 30 patients (FPCT) • 22/30 with AIS • 54.5 min vs. 20.5 min PsychogiosMN, Behme D, Schregel K, Tsogkas I, Maier IL, Leyhe JR, Zapf A, Tran J, Bähr M, Liman J, Knauth M. One-Stop Management of Acute Stroke Patients: Minimizing Door-to-Reperfusion Times. Stroke. 2017 Nov;48(11):3152-3155 41 Workflow • Direct-to-angio – Mendez et al. • 145 (MDCT) vs. 97 (FPCT) • 79/97 with LVO AIS • 70 min vs. 16 min Mendez et al. Stroke. 2018 42 21
4/4/2019 Workflow • Direct-to-angio Mendez et al. Stroke. 2018 43 Workflow • Anesthesia – Campbell et al. (Lancet Neuro., 2018) • Meta analysis 797 patients (236 GA) • 50% vs. 40% mRS < 3 at 90 days (p = 0.008) Campbell BCV et al HERMES collaborators. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol. 2018 Jan;17(1):47-53 44 22
4/4/2019 Workflow • Access – Femoral – Radial – Carotid 45 Workflow • Access – Chen et al. (n = 18) • Radial access • No difference in puncture-to-reperfusion times (~ 60 min) relative to femoral access. • Similar TICI, pass number, and mRS Chen et al. JNIS. 2019 46 23
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4/4/2019 49 Mokin et al. JNIS. 2013 50 25
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4/4/2019 53 Workflow • Access – Fjetland et al. (n = 7) • Carotid access • Access to reperfusion time 45 min. (mean) • 1 hematoma requiring surgery (manual compression for all others). • 100% TICI2b or 3 Fjetland et al. JVIR. 2018 54 27
4/4/2019 Conclusion • Standard of care • Time is brain – Minutes matter – Code Culture UCSF/ZSFG are the Stroke Centers for the Bay Area 55 Thank you Questions? Daniel.cooke@ucsf.edu 56 28
4/4/2019 Mission Protocol • Who’s eligible: +Cincinnati Prehospital Stroke Scale and Last Known Normal < 6 hours → ambulance notifies ZSFG • ZSFG RN asks for primary language, anticoagulant use, placement of 18g IV • EMS obtains vitals, IV, fingerstick glucose • Patient arrives at Mission Drop-off (hallway at ambulance entrance across from CT 1) • Welcoming committee: ED RN, MEA, ED resident and attending 57 Mission Protocol • Neurology resident joins team • ED RN draws labs off existing IV, does assessment, places transport monitor, removes metal jewelry • ED resident does rapid assessment: ABCs, FAST-ED plus threat score, focused exam to determine: stable CVA, unstable CVA, not CVA • If stable CVA: to CT on EMS gurney, weigh in on way in 58 29
4/4/2019 Mission Protocol • IV-tPA given while on CT table • If 2 nd line not established, placed on CT table • CT angiogram and perfusion • If large vessel occlusion: direct to NIR Suite 59 Mission Protocol • Launched July 2017 • Stroke metrics through 9/30/18: – Door-to-CT: 13 minutes (mean), 8 minutes (median) – Door-to-tPA (n=90): 40 minutes (mean), 34 minutes (median) – Door-to-embolectomy (groin puncture) (n=43): 99 minutes (mean), 94 minutes (median) 60 30
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4/4/2019 67 Goal of Ischemic Stroke Treatment Before Intervention After Successful Intervention Images courtesy of Dr. Joey English – Used with Permission. Results from case studies are not predictive of results in other cases. Results in other cases may vary. 68 34
4/4/2019 Workflow • Anesthesia – Henden et al. (Stroke., 2017) • AnStroke RCT 90 patients • 42% vs. 40% mRS < 3 at 90 days (p = 1) Löwhagen Hendén P, Rentzos A, Karlsson JE, Rosengren L, Leiram B, Sundeman H, Dunker D, Schnabel K, Wikholm G, Hellström M, Ricksten SE. General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke: The AnStroke Trial (Anesthesia During Stroke). Stroke. 2017 Jun;48(6):1601-1607 69 Workflow • Anesthesia – Simonsen et al. (JAMA Neuro., 2018) • GOLIATH RCT 128 patients • OR 1.9 mRS < 3 at 90 days Simonsen CZ, Yoo AJ, Sørensen LH, Juul N, Johnsen SP, Andersen G, Rasmussen M.Effect of General Anesthesia and Conscious Sedation During Endovascular Therapy on Infarct Growth and Clinical Outcomes in Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2018 Jan 16 70 35
4/4/2019 HERMES 71 AHA 2018 • “It is reasonable to select an anesthetic technique during endovascular therapy for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics. Further randomized trial data are needed.” COR, LOE ( IIa, B-R) 72 36
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