Interventional Radiology - stroke treatment

Question 1

What were the given cardiac sources of embolic stroke?

Answer 1

• MOST COMMON - atrial fribrillation
  
  • LVADs, dilated cardiomyopathy
  • Right left shunts (PFO)
  • Endocarditis

Question 2

What were the arterial sources of embolic stroke?

Answer 2

• Carotid stenosis - BIG
  
  • Intracranial atherosclerosis
  • Vertebral arteries
  • dissections

Question 3

Of all the strokes in the US, what percentage are hemorrhagic and what percentage are ischemic?

Answer 3

• 87% - ischemic
• 13% - hemorrhagic
○ Remember that ischemic can convert or transform into hemorrhages and there can be many causes of hemorrhage

Question 4

When are where was the first intra-arterial thrombolysis performed?

Answer 4

• 1988, at the university of colorado

* Young male in bar fight that experienced stroke (aphasic and hemiparetic)

Question 5

What is the standard of care for emergency stroke now?

Answer 5

• IV tpa within 3 hours of symptom onset
  
  • (remember urokinase through diagnostic catheter was first episode)
  • Can be beneficial to give tpa IV up to 4.5 hours, but the earlier the better

Question 6

In a 138 patient study, what was the size of clot that never opened with IV tpa use?

Answer 6

• Clots over 7mm never opened with IV tpa
  
  • Clots less than 5mm long are likely to open with IV tpa
  • The 5-7 range is more bad than good

Question 7

Is it better to perform endovascular stroke treatment than IV tpa?

Answer 7

• Three clinical trials in feb 2013 in NEJM showed no benefit
• This treatment is fancy tools that go in and pull out the clot, not pharm. Bust-up
*unfortunately for the field, these studies showed little benefit for ANY intra-arterial stroke therapy
BUT THE STUDIES WERE DONE IN AN UNHELPFUL WAY

Question 8

Why was there a huge 2015 re-visit in the medial literature of the efficacy of intra-arterial stroke therapy?

Answer 8

in 2013 three clinical trials showed little to no benefit of IA treatment

• however, the patient selection and the whole philosophy of studied treatment did not report the “correct” outcomes
• the new trials showed IA treatment to be much better than control
• there is now better evidence supporting a referral to IA treatment

Question 9

What is the most current revision of the AHA guidelines for endovascular management of acute stroke?

Answer 9

• Still give IV tpa
• IA thrombectomy recommended within 6 hour window for ICA and MCA clots
• Strongly recommend noninvasive vascular imaging to screen patients
• Use stent retrievers
○ Aspiration thrombectomy is also good
• Use a balloon guide catheter or distal aspiration catheter along with a stent retriever

Question 10

What values are you given in a CT perfusion scan?

Answer 10

• MTT - mean transit time
		○ Time for blood to cross a tissue bed
	• CBV - cerebral blood volume
		○ How much blood is in the tissue
		○ Intact blood volume means viable tissue