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Montpellier University Hospital, Montpellier, France

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Présentation au sujet: "Montpellier University Hospital, Montpellier, France"— 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 52.4% 45.2% Efficacité marginale, bénéfice absolu du rt-PA 7.2%( p=0.04) Hemorragies IC rt-PA: 27% vs17.6% (p=0.001) NNT=17

4 FIBRINOLYSE IV Analyse critique
Selon la severité de l’AVCI Infarctus etendu :ECASS I& II NIHSS> 20 RISQUE HEMORRAGIQUE ACCRU Selon le siège de l’occlusion: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 l’infarctus 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):215-38

7 P RadioGraphics 2006; 26:S75-S95 INFARCTUS PENOMBRE ↑MTT ↓CBV ↓ CBF 7

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.
L I M5 M2 CI M3 M6 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.

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

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

12 Wardlaw, jnnp,2007;78:405

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

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

15 Index of Cerebral Blood Flow
Volume(cm3) TTM TTP Cerebral Blood Volume Index of Cerebral Blood Flow nécrose 102,013 30,05 21,21 72,2451 4,24971 parenchyme sain 721,531 10,6 19,44 114,16 19,0266 pénombre 69,213 15,9 22,97 116,551 12,9501

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) Thrombectomy under GA Mechanical thrombectomy alone (MTB) After 4h30 Ischemic strokes secondary to large vessel occlusions are associated particularly with a high degree of morbidity and the neurological outcome is dependent mainly on the time required for recanalization. Thrombus within vessels of this size is relatively resistant to plasminogen activators delivered intravenously (2– 4). Therefore, the need to pursue and set in motion therapeutic pathways involving direct endovascular techniques is warranted and necessary. an integrated Stroke Management Protocol was agreed in August 2009 between the members of our stroke multidisciplinary team (neurologists, neuroradiologists, and anesthesiologists). A unanimously accepted common algorithm was then developed to streamline and ascertain coalescent decision making process in all stroke patients.

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

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

27 Recanalization rate TICI 3 42 cases, 84% TICI 2B + 3 44 cases, 88% n %
TICI 2A TICI 1 0% TICI 0 4 8% Total 50 100%  TICI 3 42 cases, 84% TICI 2B + 3 44 cases, 88%

28 Procedure Time All Procedures Mean time (min) Onset - Admission 171
Admission - MRI 51 MRI - Puncture 101 Puncture - Recanalization 53 Etudier les temps sans les patients rescue permet d’évaluer la prise en charge sans le délais imposé par le 2ème passage du patient par les urgences. All Procedures excluding « Rescue » Mean time (min) Onset - Admission 188 Admission - MRI 53 MRI - Puncture 95 Puncture - Recanalization 60

29 Procedural results by location
TICI 3 Procedure time (Puncture to Recanalization) Onset to recanalization time Number of Device passes NeurologicalComplication rates MCA 19/20 (86%) 40 min 296 min 1.5 2/20 (10%) BA 13/16 (81%) 55 min 506 min 2.1 3/16 (19%) ICA 10/14 (71%) 56 min 271 min 2.4 (0%) Overall 42/50 (84%) 54 min 358 min 2.0 5/50 Procedural results per location. LES COMPLICATION DECRITES DANS CE TABLEAU SONT SEULEMENT LES COMPLICATIONS NEUROLOGIQUES PROCEDURALES Groupe ACM Liste des complications dans ce groupe IMMEDIATES 1 dissection sur stenose, stent livré et puis thrombosé à posteriori 1 HAS asymptomatique   1 occlusion de A2 sur thrombectomie sylvienne             A 24 H     1 transformation hemorragique importante avec effet de masse 1 rem hemor sur TDM 24h   1 faux anévrysme _______________________________________________________ Groupe AB 1 embolie de PICA, puis echec de thrombectomie de cette PICA et sa dissection   A 24H 1 remaniement hémorragique   _________________________________________________________ Groupe ACI 1 OAP 1 HAS insulaire minime asymptomatique 1 Pettit reman hemorr de l'uncus 1 Oclusion ACP homolatéral sur une thrombectomie sylvienne A 24 H 2 remaniments hémorragiques de plus 1 tres minime HAS 1 faux anévrysme sur le meme patient de l'oclusion ACP

30 Immediate clinical results

31 Symptomatic complications EXTENSION OF INFARCTION AT 24H
Total complications N (%) 10 (20%) Asymptomatic SAH 1 (2%) PH1 A2 embolism M1 dissection (+ occlusion) PH2 PICA embolism PICA embolism (+ dissection) Asymptomatic PCA embolism Symptomatic complications N (%) 5 (10%) A2 embolism 1 (2%) M1 dissection (+ occlusion) PH2 PICA embolism PICA embolism (+ dissection) IMMEDIATE N (%) 5 (10%) Asymptomatic SAH 1 (2%) A2 embolism PICA embolism (+ dissection) Asymptomatic HSA Hemorrhagic transformation 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, 2001. SEULEMENT LES COMPLICATIONS NEUROLOGIQUES LIEES AU DISPOSITIF SONT RAPPORTEES SUR CES TABLEAUX EN PLUS, IL Y A EU ENCORE 2 FAUX ANEVRYSMES SUR LE POINT DE PONCTION, UN OAP ET UNE DISSECTION INTRACRANIENNE NON CAUSEE PAR LE DISPOSITIF, MAIS PAR UNE ANGIOPLASTIE AU BALONNET REALISEE APRES LA THROMBECTOMIE. (HI-1) small petechiae along the margins of he infarct (HI-2) more confluent petechiae within the infarcted area but without space-occupying effect. (PH-1) hematoma in <=30% of the infarcted area with some slight space-occupying effect; (PH-2) dense hematoma >30% of the infarcted area with substantial space-occupying effect or as any hemorrhagic lesion outside the infarcted area Groupe ACM Liste des complications dans ce groupe IMMEDIATES 1 dissection sur stenose PAS LIEE AU DISPOSITIF, donc pas rapportée. Le dispositif a bien marché, mais une sténose a été vue sur la série de controle. Ensuite, une angioplastie a été pratiquée qui a résulté en une dissection de l’ACM. Puis, un stent Wingspan a été livré pour traiter la dissection, mais il a thrombosé à posteriori et le patient a constitué tout le territoire d’ischémie (Mme SWEDERSKI) 1 HAS asymptomatique   1 occlusion de A2 sur thrombectomie sylvienne             A 24 H     1 transformation hemorragique importante avec effet de masse 1 rem hemor sur TDM 24h   1 faux anévrysme _______________________________________________________ Groupe AB 1 embolie de PICA, puis echec de thrombectomie de cette PICA et sa dissection   A 24H 1 remaniement hémorragique   _________________________________________________________ Groupe ACI 1 OAP 1 HAS insulaire minime asymptomatique 1 Pettit reman hemorr de l'uncus 1 Oclusion ACP homolatéral sur une thrombectomie sylvienne A 24 H 2 remaniments hémorragiques de plus 1 tres minime HAS 1 faux anévrysme sur le meme patient de l'oclusion ACP TABLEAU EXTENSION DE L’ISCHEMIE A 24H Le patient “successful thrombectomy and procedural complication” est Mr BAUMES, chez qui la PICA a été occluse et dissequée. Le patient avec la dissection ACM lors de l’angioplastie après une thrombectomie reussie est compté dans la deuxième ligne du tableau  MCA  BA  ICA EXTENSION OF INFARCTION AT 24H 6/50 (12%) Failed thrombectomy 1 Successful thrombectomy 4 Successful thrombectomy and procedural complication Procedure-related mortality: 0

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

33 3-months outcome Les pourcentages sont calculer sur les nombres d’effectifs à 3 mois et non sur 50

34 Thombectomy/stroke studies
STUDY Patients NIHSS Location Time Passes TICI 2+3 Emboli sICH Mortality mRS ≤2 Montpellier 50 15 A + P 377 2 = 92% 8% 2% 12% 54% POST Penumbra 157 16 311 n/a = 87% (TIMI) 6% 20% 41% Multi MERCI 164 19 354 2.9 68% (TIMI) 10% 34% 36% iv rt-PA 1391 11 9% 13% 49%

35 Thombectomy/stroke studies
STUDY Patients NIHSS Location Time Passes TICI 2+3 Emboli sICH Mortality mRS ≤2 Montpellier 20 15 MCA 294 1.5 = 100% 5% 0% 70% Castano et al. 19 359 1.4 = 90% 10% 20% 45% Roth et al. 8 18 n/a 1.8 = 75% PROACT II 121 17 66% (TIMI) 25% 40% PROACT II (c) 59 18% (TIMI) 2% 27%

36 Rescue thrombectomy n=24 IV Rt- Pa n=32
HISTORICAL COMPARISON OF 2 STRATEGIES: IV Rt-pa( ) VS RESCUE THROMBECTOMY ALL CASES MCA OCCLUSION (MRA) SUBMITED IN CEREBROVASCLAR DISEASES Rescue thrombectomy n=24 IV Rt- Pa n=32 IValone n=7 IV+thrombectomy n=17 Recanalization 94% NIHSS 24H 71% 36% P=0.01 mRS 90 d 81% 52% P<0.01 HIC 9% 11% DC 1 1

37

38 Inclusion per site Country Center Lead Physician # of Pts n = 141
Spain Hospital Germans Trias i Pujol de Badalona, Barcelona C. Castano 45 (32%) Switzerland Hôpitaux Universitaires de Genève, Geneva V. Mendes Pereira 29 (20.5%) Germany AKK Hospital, Essen R. Chapot 25 (18%) France Hôpital Gui de Chauliac, Montpellier A. Bonafé 20(14%) Sweden Karolinska sjukhuset, Stockholm T. Andersson 15 (10.5%) Inselspital University Hospital of Bern J. Gralla 7 (5%)

39 Patient and Stroke Characteristics
Mean age: [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%) Failed IV-tPA: 46 No clinical improvment: 20 No clinical improvment+ Imaging (TC doppler or CTA): 3 Imaging: 23 (19 TC doppler/2MRA/1CTA+MRA/1TCdoppler+MRA) Imaging type: 81 CT / 36 MR perfusion / 11 CT perfusion / 8 MR/ 1 DSA/ 4 No imaging done 39

40 Occlusion site - CoreLab
N= 143 occlusion sites over 138 patients analyzed* Localisation N (%) ICA 6 (4%) Carotid T 33 (23%) M1 66 (46%) M2 19 (13%) VB 16 (11%) PCA 2 (1%) SCA 1 (1%) *: 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 90 days F/U: modified Rankin Scores
Solitaire outcomes compared to Merci and Penumbra historical outcomes data 90 days F/U: modified Rankin Scores Revascularization rates: TIMI ≥ 2 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
mRS N (%) 27 (19%) 1 25 (18%) 2 3 13 (9%) 4 17 (12%) 5 4 (3%) 6 26 (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 1 patient without mRS evaluated at 3 months (NIHSS=12) 3 Months visits performed at +/- 2 Months for 90% 9% of visits were aboce +/- 2months window 43

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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