Transcript 08. Stents implantation to treat carotid lesions

SOFIA - BEC 2012
Acute Stroke Management
K. Mathias
Department of Radiology
Klinikum Dortmund / Germany
We started a stroke program ...
 Dortmund Society against Stroke
founded 12 years ago
 Aims:
• inform the population
• improve the logistics
• include health politicians & insurance
companies
• get more patients treated earlier
Organization of Stroke Management
• inform the population
Stroke
• inform the physicians
an
Emergency
• organize transportation to hospitals with stroke unit
and facility for neuro-interventions
• organize the pathways in your hospital
Logistics are essential
 when was the stroke detected
problem: wake-up strokes
 does the emergency physician know
where to send the patient
 when are we informed that a pt. is on the way
 keep a CT unit ready
 inform the neuro-interventional team
When the stroke occurs in the city of Dortmund itself
we have the patient in the hospital within 30 min !
CT must tell us ...
 ischemic or hemorrhagic stroke ?
 already stroke signs ?
 size of perfusion deficit ?
 still good blood volume
in the ischemic area ?
 where is the occlusion located ?
CT must tell us ...
dense media sign
ischemia, no infarction
I.K. f-85y
large perfusion defect = tissue at risk
Time Window ...
 studies on i.v. thrombolysis teached us:
 6 hours too often ICB
 3 hours too few patients
 4.5 hours optimum, but ...
Time Window ...
 some pts. have already an infarction
after 1 h
 some patients have still no infarction
after 10 h → collateral flow
 functional brain imaging much better !
I.V. Thrombolysis ...
... starts when cerebral hemorrhage is ruled out
... and is continued when CTA shows no central
artery occlusion
... ineffective
when
thrombus
>8 mm
Thrombectomy - MCA
Solitaire® EV3
M1 segment
→Solitaire® 4 mm
M2 segment
→Solitaire® 4 mm
more distal branches → thrombolysis
Technique of Thrombectomy
• 6/8-FR sheath Coral or Cello with balloon in
ICA
• 6/8-FR guiding catheter Balt IVA in ICA
• Transend® 0.014” wire
• Microcatheter Rebar 0.018”
• Solitaire® EV3
• general anesthesia
• crossing of thrombus with wire & microcatheter
• exchange of wire with Solitaire® stent
• stent released in thrombus
• after 2-3 min blocking of ICA
• suction with 30 cc syringe
• pullback of stent into guiding catheter
• removal of guiding catheter with stent
Thrombectomy MCA
A. C. St. f-73 Hemiplegic for 4 hrs CTA: MCA occlusion
Perfusion study: underperfused anterior mca territory
Thrombectomy MCA
A. C. St. f-73 Hemiplegic for 4 hrs
Angio: MCA occlusion - one posterior branch preserved Solitaire® 4 mm
Thrombectomy MCA
Solitaire® 4 mm
A. C. St. f-73
Thrombectomy MCA
Minor Stroke - After 6 months mR-Scale 1
A. C. St. f-73
FU CT after 24 hrs
Thrombectomy MCA
E. B. f-66 Aphasic and hemiplegic for 5 hrs CTA : MCA occlusion
Thrombectomy MCA
Transit time
Flow
Blood volume
E. B. f-66 Aphasic and hemiplegic for 5 hrs CT: perfusion deficit
Thrombectomy MCA
Solitaire ®
E. B. f-66 Aphasic and hemiplegic for 5 hrs CTA : MCA occlusion
Thrombectomy MCA
E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs
Thrombectomy MCA
E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs
Thrombectomy Results
patients*
age
time window
technical success
- no infarction
- minor stroke
- major stroke
mortality (30d)
228
69±22
3 - 7 hrs
222
64
139
25
5
*Own results 10-2010 - 09-2012
100%
97%
28%
61%
11%
2.2%
Conclusions
 early recanalization dramatically
improves outcomes
 functional imaging more important
than time window
 fast door to CT to Angio time must
be achieved
 there is no “I” team ... close cooperation !