Endovascular Flashcards
DAWN.
NEJM. 11/2017.
LKW. 6-24 hrs.
Thrombectomy (107) vs medical (99).
Only Trevo stent aspirator device allowed.
CTA or MRA with IC or M1 occlusion.
Clinical vs infarct mismatch by CTP or MRI using RAPID software (iSchemaView).
Group A: 80+ YOA. NIHSS>10, infarct < 31 cc
Group B: <80 YOA. NIH >20. Infarct 31-51 cc.
Measure: mod Rankin. Functional independence.
Better for thrombectomy group at 90 days. Both groups. NNT 2-3:1.
DEFUSE 3
NEJM 1/2018.
Open label thrombectomy at 6-16 hours.
ICA or M1 occlusion.
Infarct 70 cc or less, and ischemia volume to infarct volume ratio of 1.8 or more, AND absolute penumbra volume of 15cc or more.
Using DWI or CTP and RAPID softeare.
Thrombectomy vs. medical treatment.
Thrombectomy had better Rankin (1-6) and better functional independence.
Study terminated after DAWN results came out.
COMPASS. 2018
Direct aspiration not inferior to stent retrievers within six hours.
Modified Rankin about the same.
COMPASs trial. 2018.
N=27,395. W/ CAD and/or carotid dz. no recent stroke.
Outcome: stroke. MI. CV death.
ASA alone
Rivaroxaban alone.
Rivarox plus ASA.
Follow up. 36 months.
Achieving endpoint:
ASA. 5.4%
Riv. 4.9%
Riv. Plus ASA. 4.1 %
Hazard ratio Riv + ASA. Vs. ASA is 0.76.
Bleeds risk about the same.
Just ischemic strokes: .4%/yr. vs. .7%/yr.
And strokes less disabling.
Stent Retrievers
Trevo. Pro Vue. (Stryker)
Solitare (Medtronic).
MR CLEAN 2015 NEJM. N=500 Within 6 hours. Occluded distal ICA, M1, M2, A1, A2, by CTA, MRA, or angio. NIH score at least 2
IA tx ( Mechanical (usually stent), IA TPA, or both), most 87% got IV TPA also Versus control group (90% got IV tPA).
Rates of recanalization (opening of the blocked artery) were much better in the endovascular stroke treatment (EST) arm on follow-up CT angiography (CTA):
At one week following treatment, the median territory of residual stroke on neuroimaging was lower in the endovascular stroke treatment arm:
And, most importantly, functional clinical outcome on the modified Rankin Scale at 90 days post-stroke was significantly shifted toward better outcomes: for
Mechanical Thrombectomy Overview
Evidence-based guidelines.
MT, plus TPA within 4.5 hrs, recommended for large artery occlusion in anterior circulation within 6 hours.
MT shouldn’t prevent IVTPA, and IVTPA shouldn’t delay EMT.
MT performed as soon as possible.
Large intracranial vessel occlusion should be diagnosed with CTA or MRA.
High age alone not enough to withhold MT.
If anticoagulated or contraindicated for TPA, then proceed to IAMT.
Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke
NEJM
5/2020
N=656 at 41 institutions in China.
CONCLUSIONS
In Chinese patients with acute ischemic stroke from large-vessel occlusion, endovascular thrombectomy alone was noninferior with regard to functional outcome, within a 20% margin of confidence, to endovascular thrombectomy preceded by intravenous alteplase administered within 4.5 hours after symptom onset.
But secondary outcomes showed better reperfusion.
CODICIA
Cerebrovascular Disease. 2015.
https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=26184495
The RoPE score predicted the presence versus the absence of RLSh documented by contrast transcranial Doppler (c-statistic = 0.66). For patients with documented RLSh by c-TCD, shunt severity was correlated with increasing RoPE score (rank correlation (r) = 0.15, p = 0.01). Among 293 patients who had both c-TCD and TEE performed, c-TCD was more sensitive (98.7%) for detecting RLSh. Of the 97 patients with no PFO identified on TEE, 28 (29%) had a large amount of RLSh seen on c-TCD.
PROACT II
1999
Up to six hours
Better outcomes EVT w/ IA thrombolysis.
High bleed rate.
HERMES
Lancet. 2016.
Meta Analysis.
EVT. Better outcomes at ninety days.
