1. Time Is Brain: Advanced Stroke Treatment Grahame C Gould, MD Jefferson Neurosurgical Associates at Main Line Health, Bryn Mawr Hospital Division of Neurovascular & Endovascular Surgery Department of Neurological Surgery Thomas Jefferson University April 26, 2012 Christopher Reid, MD Bryn Mawr Hospital Neurologist

2. 2 Explaining Stroke Stroke is a brain attack!

3. Be Stroke Smart Recognize: stroke symptoms Reduce: stroke risk Respond : at the first sign of stroke, Call 911 immediately! The 3 R’s of Stroke:

4. Definition of Stroke Sudden brain damage Lack of blood flow to the brain caused by a clot or rupture of a blood vessel Ischemic = Clot (makes up approximately 85% of all strokes) Hemorrhagic = Bleed - Bleeding around brain - Bleeding into brain EmbolicThrombotic

5. Brain Attack! Stroke is a “ Brain Attack. ” Stroke happens in the brain not the heart Stroke is an emergency. Call 911 for emergency treatment.

6. Stroke Symptoms Sudden and severe headache Trouble seeing in one or both eyes Sudden dizziness Trouble walking Sudden numbness or weakness of face, arm or leg Sudden confusion Trouble speaking If you observe any of these symptoms, call 911 immediately. Every minute matters!

7. Think FAST! F = Face: ask the person to smile A = Arm: ask the person to raise both arms S = Speech: ask the person to speak a simple sentence T = Time: to call 911 Every minute matters!

8. TIA or Mini-Stroke Transient ischemic attack (TIA) is a warning sign of a future stroke - more than 1/3 of TIA patients will have a future stroke Symptoms of TIAs are the same as stroke TIA symptoms can resolve within minutes or hours It is important to seek immediate medical attention if you suspect that you are having or have had a TIA

9. Approximately 80% of strokes are preventable! National Stroke Association developed the following guidelines to help people reduce their risk for stroke …

10. National Stroke Association’s Stroke Prevention Guidelines 1.Know your blood pressure. Have it checked at least annually. If it is elevated, work with your doctor to control it. 2.Find out if you have atrial fibrillation (AF) – a type of irregular heartbeat. If you have it, work with your doctor to manage it. 3.If you smoke, stop.

11. National Stroke Association’s Stroke Prevention Guidelines (continued) 4. If you drink alcohol, do so in moderation. 5. Know your cholesterol number. If it is high, work with your doctor to control it. 6. If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.

12. National Stroke Association’s Stroke Prevention Guidelines (continued) 7. Include exercise in your daily routine 8. Enjoy a lower sodium (salt) and lower fat diet 9.If you have circulation problems, work with your doctor to improve your circulation. 10.If you experience any stroke symptoms, call 911 immediately. Every minute matters!

13. Acute Stroke Treatments Ischemic stroke (Brain Clot) Clot busting medication: t-PA (Tissue Plasminogen Activator) Clot-removing devices: Merci Retriever, Penumbra Hemorrhagic Stroke (Brain Bleed) Clipping Coiling

14. 14 Treatment of Acute Ischemic Stroke

15. Time Is Brain!!!

16. Ischemic Penumbra Area of brain with compromised blood supply that can be salvaged by timely intervention Infarct <8 mL/100 g/min Penumbra 8-20 mL/100 g/min Normal 50 mL/100 g/min

17. Acute Management of Stroke Rapid identification and transport to hospital Efficient triage and evaluation at hospital Support normal physiology to enhance collateral perfusion –Oxygen, temperature, glucose, permissive hypertension Appropriate patient selection for IV or IA thrombolysis

18. Acute Stroke Therapies (Evidence Basis) Intravenous thrombolysis –European Cooperative Acute Stoke Study (ECASS) 1-3 –Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) 4 –National Institute of Neurologic Disease and Stroke (NINDS) 5 Intra-arterial thrombolysis –Prolyse in Acute Cerebral Thromboembolism (PROACT I 6 and II) 7 Combined IV/IA thrombolysis –Interventional Management of Stroke (IMS 8 ) trial; IMS-3 underway Mechanical thrombectomy –Safety and Efficacy of Mechanical Embolectomy in Acute Ischemic Stroke; MERCI trial 9 1. Hacke W et al. ECASS JAMA 274:1017-25, 1995. 2. Hacke W et al. ECASS II Lancet 352:1245-51, 1998. 3. Hacke W et al. ECASS N Engl J Med 25:1317-29, 2008. 4. Clark WM et al. ATLANTIS JAMA 282:2019-26, 1999. 5. NINDS rt-PA Study Group. N Engl J Med 333:1581-87, 1995. 6. Del Zoppo GJ et al. PROACT Stroke 29:4-11, 1998. 7. Furlan A et al. PROACT II JAMA 282:2003-2011, 1999. 8. IMS Study Investigators. Stroke 35:904-11, 2004. 9. Smith WS et al. MERCI. Stroke. 2005 Jul;36(7):1432-8

19. Thrombolysis and Acute Stroke Management 3 to 4.5 hour window for initiation of IV lytic 6 hour window for IA lytic Physiologic imaging for mechanical thrombectomy beyond 6 hour window IA thrombolysis and/or thrombectomy of basilar artery up to 24 hour window given severity of disease without treatment

20. Physiologic imaging in Acute Stroke Computed Tomography Perfusion imaging (CTP) –Identifies brain penumbra and infarct –Used to select patients for aggressive endovascular therapy Computed Tomography Angiographic imaging (CTA) –Rapid imaging of the entire neurovascular axis –Identifies therapeutic targets and anatomic considerations in treatment

21. CTP in Acute Stroke CBFMTT CBV (Completed infarct, will not benefit from revascularization)

22. CTP in Acute Stroke CBF MTTCBV (Brain at risk w/o infarct, may benefit from revascularization)

23. CTA in Acute Stroke

25. Endovascular Tools for Stroke Treatment Merci ® Retriever

26. Endovascular Tools for Stroke Treatment Penumbra ® Stroke Device Stroke device for mechanical thrombectomy Higher rates of recanalization (~80%)

27. Solitaire ® – Stent Retrieval Device Recanalization rates approaching 90% Recently received FDA approval

28. Risks of Acute Stroke Intervention Failure to improve Hemorrhage Worsening of neurological deficit (NINDS) 1 –6-7% symptomatic ICH in tPA group (MERCI) 2 –7.8% symptomatic ICH 1.NINDS rt-PA Study Group. N Engl J Med 333:1581-87, 1995. 2.Smith WS et al. MERCI. Stroke. 2005 Jul;36(7):1432-8

29. Benefits of Acute Stroke Intervention (NINDS) 1 –Patients treated with IV tPA were 30% more likely to have minimal or no disability at 90 days (MERCI) 2 –46% of Patients successfully treated with mechanical thrombectomy had only slight disability or better at 90 days 1.NINDS rt-PA Study Group. N Engl J Med 333:1581-87, 1995. 2.Smith WS et al. MERCI. Stroke. 2005 Jul;36(7):1432-8

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