Intervention in Stroke- Intra-arterial thrombolyis and Mechanical thrombectomy Dr Sanjeev Nayak Consultant Neuroradiologist

Stroke is the major cause of disability in the developed world Stroke is the major cause of disability in the developed world In the UK it accounts for 11% of deaths, it results in significant morbidity of people who survive and represents a substantial health and resource problem (NICE 2009) In the UK it accounts for 11% of deaths, it results in significant morbidity of people who survive and represents a substantial health and resource problem (NICE 2009) Its early diagnosis is important as its treatment is dependent on the time elapsed since the onset of the symptoms. Delay in diagnosis and treatment translates into increase neuronal loss and thereby increased morbidity. Its early diagnosis is important as its treatment is dependent on the time elapsed since the onset of the symptoms. Delay in diagnosis and treatment translates into increase neuronal loss and thereby increased morbidity. Reperfusion remains the mainstay of acute ischemic stroke treatment [4] Reperfusion remains the mainstay of acute ischemic stroke treatment [4] Introduction

IV rtPA therapy for acute ischemic stoke improves 3-month outcome if given within 3 hours of onset. IV rtPA therapy for acute ischemic stoke improves 3-month outcome if given within 3 hours of onset. However > 50% do not demonstrate a favourable outcome However > 50% do not demonstrate a favourable outcome In several series mechanical clot disruption with IAT has been shown to achieve higher recanalization rates. In several series mechanical clot disruption with IAT has been shown to achieve higher recanalization rates.

Stroke in STOKE Period : Jan 2010 to August 2010 (8 Months) Total Number of Acute Strokes: 758 patients Patients treated with IV rtPA : 39 patients Patients treated with IA rtPA ± Mechanical thrombectomy : 18

Subjects and Methods: A review of 18 patients presenting to our institution over a period of 8 months with acute stroke where CTA confirmed the presence of a thrombus These patients were resistant to IV rtPA and underwent partial to complete clot removal either with IA thrombolysis or in conjunction with mechanical thrombectomy. 13 of the 18 patients underwent mechanical thrombectomy Solitaire AB device was used in 12 of the 13 patients Thrombus-aspiration and guide wire thrombus dislodgement was attempted in 1.

Clinical Protocol: Neurological examination was performed on all acute stroke patients either by a neurologist or a stroke physician. Main Inclusion Criteria: Anterior Circulation Strokes: Age < 80 yrs NIHSS ≥ 8 Onset of symptoms within 8 hours of treatment No large hypodensity on plain CT Head Occlusion of a major cerebral artery on CT Angiogram Posterior Circulation Strokes: Time window extended up to 12 hours No haemorrhage on presenting CT Head.

An admission and post-interventional NIHSS score calculated on all patients. A 30-day MRS was then recorded on all these patients. Clinical follow-up and rehabilitative care was then undertaken through a multi-disciplinary approach

Imaging Protocol : Imaging Protocol : All patients underwent plain CT Head and CTA arch to COW All patients underwent plain CT Head and CTA arch to COW Patients with intracranial major vessel/cervical carotid occlusion secondary to a thrombus were included for the intervention Patients with intracranial major vessel/cervical carotid occlusion secondary to a thrombus were included for the intervention Occlusion were either present at proximal M1 segment of MCA, M1/M2 junction, terminal ICA or basilar occlusion Occlusion were either present at proximal M1 segment of MCA, M1/M2 junction, terminal ICA or basilar occlusion TIMI scores were recorded post procedure TIMI scores were recorded post procedure Post procedural CT was performed at 24 hours and repeated at necessary intervals depending on the clinical status of the patient. Post procedural CT was performed at 24 hours and repeated at necessary intervals depending on the clinical status of the patient.

Anti-thrombotic protocol 0.9 mg/Kg rtPA is the total dose per patient 0.9 mg/Kg rtPA is the total dose per patient Of which 0.6 mg/kg is adminsterted IV upon clinical and imaging diagnosis of acute stroke (Bridging dose) Of which 0.6 mg/kg is adminsterted IV upon clinical and imaging diagnosis of acute stroke (Bridging dose) 10% of the IV dose is given as a bolus. 10% of the IV dose is given as a bolus. 0.3 mg/Kg is given intra-arterially in the neurointerventional angio suite. 0.3 mg/Kg is given intra-arterially in the neurointerventional angio suite. A maximum of 30 mg rtPA is administered intra-arterially A maximum of 30 mg rtPA is administered intra-arterially 3 of our patients did not receive rTPA and only mechanical thrombectomy was performed in them. 3 of our patients did not receive rTPA and only mechanical thrombectomy was performed in them. *One fell off the CT table and there was concern about any bleed *One fell off the CT table and there was concern about any bleed *In other 2 the time of onset of symptoms was not known *In other 2 the time of onset of symptoms was not known

Thrombectomy Protocol using a Solitaire AB device Interventions performed via femoral approach Interventions performed via femoral approach 6F guiding catheter placed in ICA/Vertebral artery 6F guiding catheter placed in ICA/Vertebral artery DSA performed to visualise the location of thrombus DSA performed to visualise the location of thrombus Clot passed with a microwire and a 18 microcatheter Clot passed with a microwire and a 18 microcatheter Super selective contrast injection performed via the microcatheter to define the distal end of the clot. Super selective contrast injection performed via the microcatheter to define the distal end of the clot. Solitaire AB device was then placed within the clot for 3-5 m Solitaire AB device was then placed within the clot for 3-5 m Entire system withdrawn back into the guiding catheter with 50mls of negative suction applied at the level of guiding catheter Entire system withdrawn back into the guiding catheter with 50mls of negative suction applied at the level of guiding catheter Up to 3 attempts performed Up to 3 attempts performed

46 yr. old male with presenting NIHSS score of 15

Micro catheter RunSolitaire-AB in position

NIHSS improved from 15 to 3

PRE AND POST

THROMBUS

6-8 hours since onset of AC symptoms < 80 year-old <12 hours since onset of PC symptoms <80 year-old CT: no established infarction CTA Thrombus on CTA: bridging IV thrombolysis with 0.6mg/kg + remaining 0.3 mg/kg IA on table +/-thrombectomy CT: no bleed No contra- indication*

AgeSex Symptoms to presentation interval(mins) Clinical presentation CTA findings 1.68m300 Headache 7/7, collapse, GCS 6,intubated Distal basilar and P1 seg of PCA thrombosis 2.67f310 Right facial, UL and LL weakness, dysarthria Thrombosis of left M1 and M2 3.65m540 R facial LMN palsy, L 6 th N palsy, diplopia, profound ataxia and confusion Basilar artery thrombosis 4.53m95 Right facial weakness (LMN), dysarthria, Right vertebral art thrombosis (intra dural seg) 5.47m180 Facial and limp weakness, dysarthria M2 segment thrombosis 6.65m650 Profound ataxia, left facial, arm and leg weakness plus left nystagmus Left vertebral and basilar thrombus 7.70m55 Right LMN facial weakness, nystagmus Small basilar thrombus 8.76m85 Left dense hemiplegia Complete occlusion of M2 9.71m40 Right sided weakness and aphasia M3/4 and A2 thrombosis 10.46m60 Left sided weakness M1 thrombosis 11.81m210 Left dense hemiplegia, left conjugate gaze and aphasia – Right TACS Complete occlusion of M m120 Right dense hemiplegia, hemi anopia and aphasia – Left TACS Occlusion of M f60 Dysphasia, right facial, right UL 0/5, right LL 2/5 Occlusion of M m150 Right dense hemiplegia, aphasia and right neglect – Left TACS Occlusion of paraclinoid ICA involving M1 and A1 segments 15.65f180 Left sided weakness Occlusion of M1 and part of M mNK Found collapse with GCS 4 Basilar thrombus and left PCA 17.22f210 Right sided UMN signs, left conjugate gaze, reduced GCS Thrombosis of M1 segment of MCA 1843M120 Left Sided weakness Right MCA thrombotic occlusion

NIHHSOnadmissionTime To Tx ( hrs) Duration Of Tx IAMT No of Solitaire passes Post Rx TIMI Score Post Rx NIHHSscore MRS on discharge 1.BS6065NN-3BS YN BS60240YY*-2BS4 4.BS12090YYNA3BS YN BS60105YN-3BS1 7.BS125105YN-3BS YY YY YY NY NY YY NY YY BS60170YYNA3NA NYNA YY1300

Results Time of onset to A&E presentation Anterior Circulation (12 patients) : 40 min to 310 min (Median value 150 mins) Posterior Circulation (6 patients) : 55 min to 650 min (Median value 300 min) 1 patient with no known time onset. Common Presenting Symptoms: Anterior Circulation: Dense hemiparesis, neglect, dysphasia Posterior Circulation: Headache, profound ataxia, cranial nerve palsies, collapse CT Head : No established infarction or intracranial bleed. CTA : Major intracranial vessel occlusion

Time to Treatment (A&E to angio suite): 60 min to 280 min (median 105 min) Duration of Interventional Procedure: 60 min to 240 min (median 102 min) Mechanical Thrombectomy: 13 of 18 patients (Solitaire 12 patients) Number of passes with Solitaire: 1 to 4 passes (median 2 pass) 12 Anterior Circulation Strokes: Admission NIHHS: Between 8 and 31 (median 16)

AOL recanalization and TIMI reperfusion scoring system from IMS I review AOL indicates arterial occlusive lesion; TIMI, Thrombolysis in Myocardial Infarction Score AOL Recanalization Score TIMI Reperfusion 0 No recanalization of the primary occlusive lesion 0 No perfusion I Incomplete or partial recanalization of the primary occlusive lesion with no distal flow 1 Perfusion past the initial occlusion, but no distal branch filling II Incomplete or partial recanalization of the primary occlusive lesion with any distal flow 2 Perfusion with incomplete or slow distal branch filling III Complete recanalization of the primary occlusion with any distal flow 3 Full perfusion with filling of all distal branches, including M 3, 4

Anterior Circulation Strokes (12 patients): Pre-TXNIHHSPost-TXNIHHSImprovement Discharge MRS score Worse4* Worse4*

Anterior Circulation Strokes (12 patients) MT performed in 10 patients (Solitaire) TIMI 3 recanalization: 8 (80%) * MT aborted in 1 patient due to anaesthetic concerns * MT unsuccessful in 1 patient

Improvement in NIHHS score of ≥ 4 : 10 patients (83.33%) Discharge MRS of ≤ 2 : 7 patients (58.33%) Discharge MRS of 3: 1 patient (8.33%) Discharge MRS of 4 : 4 patients (33.33%) *MT not performed in 1 patient (only IA given) *MT aborted in 1 as the anaesthetist raised concerns of bleeding *MT performed in 1 but no revascularisation acheived. *MT successful in 1 but developed patchy infarction. Anterior Circulation Strokes (12 patients)

Posterior Circulation Strokes (6 patients) : TIMI SCORE Discharge MRS (locked in)

Posterior Circulation strokes (6 patients) 3 patients underwent MT (50%) 3 treated with IA (50%) Complete Recanalization (TIMI 3) : 5 patients (83.33%) Discharge MRS of ≤ 2 : 4 patients (66.66%) MRS of 4 : 1 patient MRS of 5 (Locked in) : 1 patient

REVIEW OF 18 CASES OUR RESULTS: Recanalization Rates : (TIMI III 72%) Recanalization achieved with Solitaire Device : 91% TIMI III Discharge mRS of ≤ 2 : 11 patients (61%) Multi Merci Trial Recanalization Rates (TIMI II/III) : 68% (TIMI III not reported) mRS scores ≤ 2: 36% Penumbra Trial Recanalization Rates (TIMI II/III: 82% ) (TIMI III: 27%) mRS scores ≤ 2: 25%

72 year old male, NIHSS improved from 22 to 6 in 24hrs

43 yr. old male, Mr L, Presented at 21:45 hrs. Friday night

1 st Pass with Solitaire Device

Intra-Arterial with 23mg rtPA 2 nd Pass with Solitaire

Complete revascularization, NIHSS improved from 15 to 0 Patient Discharged on Sunday afternoon!!

61 yr old male found collapsed GCS 4

2 passes with Solitaire

IA rtPAComplete Revascularization

Modified Rankin Scale IndependentDependent NoMild Moderate Moderately Severe

Conclusion Early interventions in acute stroke reduces patient morbidity and mortality and is extremely cost- effective. Early interventions in acute stroke reduces patient morbidity and mortality and is extremely cost- effective. Always aim to achieve complete revascularisation in suitable patients Always aim to achieve complete revascularisation in suitable patients The relationship between reperfusion and clinical outcomes, is not linear and depends on other factors including intensity and duration of the ischemia, baseline stroke severity, collateral circulation, cerebral perfusion pressure, lesion location and lesion volume The relationship between reperfusion and clinical outcomes, is not linear and depends on other factors including intensity and duration of the ischemia, baseline stroke severity, collateral circulation, cerebral perfusion pressure, lesion location and lesion volume