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Montpellier University Hospital, Montpellier, France Department of Interventional Neuroradiology Department of Neurology Department of Intensive Care and.

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Présentation au sujet: "Montpellier University Hospital, Montpellier, France Department of Interventional Neuroradiology Department of Neurology Department of Intensive Care and."— Transcription de la présentation:

1 Montpellier University Hospital, Montpellier, France Department of Interventional Neuroradiology Department of Neurology Department of Intensive Care and Anesthesiology Emergency Department – Head&Neck Unit

2 FIBRINOLYSE IV Intérêt rt-PA IV dans les 3H (NINDS,1995) mRs 0 &1:50% vs 38% (12% bénéfice absolu ou 30% bénéfice relatif) Extension de la fenêtre thérapeutique :4H30 (ECASS3, 2008) mais avec un bénéfice relatif plus faible Fibrinolyse IV associée à une augmentation significative du risque HIC

3 ECASS 3 W.Hacke, N.Engl J Med,2008;259:1317 Randomisée, multicentrique,rt-PA entre 3H et 4H30 contre placebo, outcome à J90 Efficacité marginale, bénéfice absolu du rt-PA 7.2%( p=0.04 ) Hemorragies IC rt-PA: 27% vs17.6% (p=0.001) NNT= % 45.2%

4 FIBRINOLYSE IV Analyse critique Selon la severité de lAVCI –Infarctus etendu :ECASS I& II –NIHSS> 20 –RISQUE HEMORRAGIQUE ACCRU Selon le siège de locclusion:taux recanalisation –8.7% ACI –35.2% M1-ACM –53.8% M2-ACM –65.9% M3-ACM Del Zoppo,ann.neurol.1992;1:78-86

5 SCANNER C-/ AVC PHASE AIGUE Signes précoces ACM avant 3H(+75% des cas) –Hypodensite NGC –Effacement ruban cortical insulaire –Augmentation de la teneur en H2O (hypodensité corrélée à linfarctus final; œdème sans hypoattenuation corrélé à rVSC=tissu viable) ( von Kummer, Radiology, 2001) –Accord inter-observateur médiocre –Score ASPECTS/ Thrombolyse IV (Dzialowski, Stroke 2006) 7 favorable; 2 risque hémorragique Signe ACM hyperdense= thrombus –Sensibilité faible (27-34%), sans valeur pronostique

6 SELECTION DES PATIENTS SCANNER DE PERFUSION Couverture anatomique restreinte:20mm irradiation non négligeable ( 3mSev) Tracking de bolus Infarctus : rCBV cartographie (< 2.5ml/100mg) Pénombre : MTT. cartographie (>145%) Neurotherapeutics. 2011;8(1):19-27 Neuroimaging Clin N Am. 2011;21(2):215-38Neurotherapeutics. Neuroimaging Clin N Am.

7 RadioGraphics 2006; 26:S75-S95 CBV MTT CBF PP PENOMBREINFARCTUS

8 SELECTION DES PATIENTS IRM DWI/FLAIR MISMATCH Circulation antérieure: –Score ASPECTS:>7 (facteur de bon pronostic) A.Demchuk, Stroke, 2005;36:2110 –Transposition cartographie ADC P.Barber,J Neurol Neurosurg Psychiatry.2005;76:1528 K.Kimura, Stroke, 2008;39:2388 (mauvais pronostic si 5) T.Nezu, Neurology 2010 (aspects DWI 5corrélé à une augmentation du taux sICH( OR 4.7); 4 corrélé au taux de morbidité(OR 3.6) –volume: DWI lesion vol facteur prédictif HIC M.Lansberg, Stroke, 2007;38:2275 (OR 1.42 pour 10ml DWI) Circulation postérieure:pc-ASPECTS 8 V.Puetz, Stroke.2008;39:2485

9 Score ASPECTS (0-10) : étendue AVCI territoire ACM. Coter 1 point = normal; Coter 0= ischémie régions corticale (M1, M2, M3, M4, M5, M6 et I) sous corticale (C, CI et L). M1: cortex antérieur ACM, M2: cortex latéral ACM, M3: cortex postérieur ACM, M4, M5 et M6 sont les points respectivement au dessus de M1, M2 et M3 ; I: cortex insulaire C: tête noyau caudé, L: noyau lentiforme et CI: genou capsule interne. M1 I M2 M3 M4 M5 M6 C L CI

10 Time from Symptom Onset in Acute StrokePetkova et al Radiology: : December 2010

11 Bar.Ch,58ans,hémiplegie g masive, NHISS=20, <3H, ASPECTS =5 DIFFUSION/PERFUSION MISMATCH

12 Wardlaw, jnnp,2007;78:405

13 ASPECTS =2,deficit BF gauche, 4H30 VOLUME INFARCTUS CEREBRAL

14 Cartographie du TTP Nécrose (ADC) pénombre Parenchyme sain AVC

15 Volume(cm 3 )TTMTTP Cerebral Blood Volume Index of Cerebral Blood Flow nécrose102,01330,0521,2172,24514,24971 parenchyme sain721,53110,619,44114,1619,0266 pénombre69,21315,922,97116,55112,9501

16 Imagerie de diffusion b=10000i : phase aigue Imagerie FLAIR : 5 jours après AVC

17 ASPECTS FOSSE POST

18 Pc-ASPECTS=3

19 Pc-ASPECTS=2

20 Thrombectomie mécanique CATCH MERCI PENUMBRA SOLITAIRE

21 Technical considerations General Anesthesia & Femoral Approach Guiding catheter: 6F for VA; 8F or 9F balloon guiding catheter for ICA (aspiration during system pull-back) Microcatheter at least.021 in of ID Microguidewire in Bolus of heparine IV (1000 IU after femoral puncture plus 1000 IU at the end of first hour), no antiplatelet agents Solitaire FR eV3 After the procedure: no anticoagulation therapy at least for 24 hours, CT after the procedure and CT or MRI the day after.

22 Protocol for acute stroke intervention Rescue (failed IV Fibrinolysis/MCA) –IV Fibrinolysis 0.9 mg/kg (IV bolus 10%) –Clinical Revaluation at 60 minutes If NIHSS > 7 Thrombectomy Combined/Bridging (ICA-MCA Tandem, Carotid T, BA) –IV Fibrinolysis 0.9 mg/kg (IV bolus 10%) –Thrombectomy under GA Mechanical thrombectomy alone (MTB) –After 4h30

23 Inclusion/Exclusion: Inclusion - A stroke with relevant deficit - Between 0 and 6H in the anterior circulation OR unknown onset of symptoms (but +ve FLAIR and –ve T2) - No time limit in the posterior circulation - Presence of arterial vascular occlusion on MRA (ICA-M1 TANDEM or M1-M2 or CAROTID T or BA) Exclusion - ASPECT score < 5 for the MCA territory (on b1000) - Extensive brainstem lesions - Spontaneous improvement of the NIHSS (NIHSS < 7) - High degree of deficit prior to insult

24 Aspect=7 68years old women Symptoms onset= H+2H35 Admission NIHSS = 17

25 before after Solitaire FR Thrombolysis IV = (H+3h20) Reevaluation + 60 mm = NIH 18 Rescue : Solitaire FR thrombectomy(+6h20)

26 Control CT day 1 Hospital discharge D10 NIHSS= 10 mRS =1 D90

27 Recanalization rate TICI 342 cases, 84% TICI 2B cases, 88% n% TICI 34284% TICI 2B24% TICI 2A24% TICI 100% TICI 048% Total50100%

28 Procedure Time All ProceduresMean time (min) Onset - Admission171 Admission - MRI51 MRI - Puncture101 Puncture - Recanalization53 All Procedures excluding « Rescue »Mean time (min) Onset - Admission188 Admission - MRI53 MRI - Puncture95 Puncture - Recanalization60

29 Procedural results by location TICI 3Procedure time (Puncture to Recanalization) Onset to recanalizatio n time Number of Device passes Neurologica lComplicati on rates MCA 19/20 (86%) 40 min296 min1.52/20 (10%) BA 13/16 (81%) 55 min506 min2.13/16 (19%) ICA 10/14 (71%) 56 min271 min2.40 (0%) Overall 42/50 (84%) 54 min358 min2.05/50 (10%)

30 Immediate clinical results

31 Complications MCA BA ICA IMMEDIATEN (%) 5 (10%) Asymptomatic SAH1 (2%) A2 embolism1 (2%) PICA embolism (+ dissection)1 (2%) Asymptomatic HSA1 (2%) Hemorrhagic transformation1 (2%) EXTENSION OF INFARCTION AT 24H6/50 (12%) Failed thrombectomy1 Successful thrombectomy4 Successful thrombectomy and procedural complication1 PH-1: hematoma 30% of the infarcted area with slight space-occupying effect PH-2: dense hematoma >30% of the infarcted area with substantial space- occupying effect or any hemorrhagic lesion outside the infarcted area Pessin et al, 1990; Wolpert et al, 1993; Berger et al, Procedure-related mortality: 0 Total complicationsN (%) 10 (20%) Asymptomatic SAH1 (2%) PH11 (2%) A2 embolism1 (2%) M1 dissection (+ occlusion)1 (2%) PH21 (2%) PICA embolism1 (2%) PICA embolism (+ dissection)1 (2%) Asymptomatic SAH1 (2%) PH11 (2%) Asymptomatic PCA embolism1 (2%) Symptomatic complicationsN (%) 5 (10%) A2 embolism1 (2%) M1 dissection (+ occlusion)1 (2%) PH21 (2%) PICA embolism1 (2%) PICA embolism (+ dissection)1 (2%)

32 PATIENT 12:NHISS WORSENING FROM 10 IN ADMISSION TO 16 AT DISCHARGE ACA OCCLUSION AFTER T REVASCULARIZATION DURING A COMBINED PROCEDURE efore AfterBefore After

33 3-months outcome

34 Thombectomy/stroke studies STUDYPatientsNIHSS Locatio n TimePassesTICI 2+3 Embol i sICHMortalitymRS 2 Montpellier5015A + P = 92% 8%2%12%54% POST Penumbra15716A + P311n/a = 87% (TIMI) n/a6%20%41% Multi MERCI16419A + P % (TIMI)n/a10%34%36% iv rt-PA139111A + Pn/a 9%13%49%

35 Thombectomy/stroke studies STUDYPatientsNIHSS Locatio n TimePassesTICI 2+3 Embol i sICHMortalitymRS 2 Montpellier2015MCA = 100% 5%0% 70% Castano et al.2019MCA = 90% 10% 20%45% Roth et al.818MCAn/a = 100% n/a0% 75% PROACT II12117MCA % (TIMI) n/a10%25%40% PROACT II (c)5917MCA % (TIMI) n/a2%27%25%

36 HISTORICAL COMPARISON OF 2 STRATEGIES: IV Rt-pa( ) VS RESCUE THROMBECTOMY ALL CASES MCA OCCLUSION (MRA) Rescue thrombectomy n=24 IV Rt- Pa n=32 Recanalization94% NIHSS 24H 81%52% P=0.01 9% 11% HIC 71%36% DC1 1 IValone n=7 IV+thrombectomy n=17 mRS 90 d P<0.01 SUBMITED IN CEREBROVASCLAR DISEASES

37

38 Inclusion per site CountryCenter Lead Physician # of Pts n = 141 Spain Hospital Germans Trias i Pujol de Badalona, Barcelona C. Castano45 (32%) Switzerlan d Hôpitaux Universitaires de Genève, Geneva V. Mendes Pereira 29 (20.5%) GermanyAKK Hospital, EssenR. Chapot25 (18%) France Hôpital Gui de Chauliac, Montpellier A. Bonafé20(14%) SwedenKarolinska sjukhuset, StockholmT. Andersson 15 (10.5%) Switzerlan d Inselspital University Hospital of Bern J. Gralla7 (5%)

39 Patient and Stroke Characteristics Mean age: 66.3 [20-89] Female: 62 (44%) Median NIHSS score: 18 [1-32] IV-tPA administered: 74 (52%) 0.6mg/kg: mg/kg: 49 - Dose not specified: 14 –Failed IV-tPA: 46 (32%) –Bridging: 28 (20%) No IV-tPA administered: 67 (48%) –Contraindication to IV-tPA: 56 (40%) –Direct to IA with no contraindication to IV-tPA: 11 (8%)

40 Occlusion site - CoreLab LocalisationN (%) ICA6 (4%) Carotid T33 (23%) M166 (46%) M219 (13%) VB16 (11%) PCA2 (1%) SCA1 (1%) N= 143 occlusion sites over 138 patients analyzed* *: 2 patients not evaluable: Angiopplasty/ stent proxy carotid. Not clear distal clot removal performed Stent left ICA origin. Stenosis 70%. No intracranial occlusion treated. 1 patient not evaluated due to missing imaging (pt ).

41 Solitaire outcomes compared to Merci and Penumbra historical outcomes data Revascularization rates: TIMI 2 Scores 90 days F/U: modified Rankin Scores References: 1.Mechanical thrombectomy for Acute ischemic stroke,WS Smith et al Stroke 2008; 39: The penumbra pivotal stroke trial: Stroke, 2009; 40:

42 mRS grade at 90 days (site evaluation)

43 Patient Outcome at 90 days mRSN (%) 027 (19%) 125 (18%) (9%) 417 (12%) 54 (3%) 626 (18%) mRS 2: 55% Morbidity (mRS>2): 34/141 (24%) Mortality : 29/141 (20.5%) 3 patients lost to Follow-up considered as worst outcome

44 CONCLUSIONS Validity of patient selection based on DWI derived ASPECT Score 5 and clinical mismatch, Safety of bridging strategy combining IV lytics and mechanical thrombectomy ( low rate of symptomatic IC hemorragic complications), Significant 3 months improvment of clinical outcome in MCA occlusion (70% mRS 2).


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