Acute Stroke Management 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 inform the physicians organize transportation to hospitals with stroke unit and facility for neuro-interventions organize the pathways in your hospital Stroke an Emergency
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 large perfusion defect = tissue at risk I.K. f-85y
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 !
... starts when cerebral hemorrhage is ruled out 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 M1 segment →Solitaire® 4 mm 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
Minor Stroke - After 6 months mR-Scale 1 Thrombectomy MCA Minor Stroke - After 6 months mR-Scale 1 A. C. St. f-73 FU CT after 24 hrs
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 CTA : MCA occlusion
E. B. f-66 Aphasic and hemiplegic for 5 hrs CT: perfusion deficit Thrombectomy MCA Transit time Flow Blood volume E. B. f-66 Aphasic and hemiplegic for 5 hrs CT: perfusion deficit
E. B. f-66 Aphasic and hemiplegic for 5 hrs CTA : MCA occlusion Thrombectomy MCA Solitaire ® E. B. f-66 Aphasic and hemiplegic for 5 hrs CTA : MCA occlusion
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
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* 228 100% age 69±22 time window 3 - 7 hrs technical success 222 97% - no infarction 64 28% - minor stroke 139 61% - major stroke 25 11% mortality (30d) 5 2.2% *Own results 10-2010 - 09-2012
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 !
We have efficient techniques to prevent strokes today ... ... but we have to organize the logistics!