Acute Carotid Occlusions

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Presentation transcript:

Acute Carotid Occlusions SOFIA - BEC 2012 Treatment of Acute Carotid Occlusions K. Mathias*, A. Ranft*, G. Rudel** *Department of Radiology **Department of Neurology Klinikum Dortmund / Germany

Symptomatic Carotid Stenosis Emergency-CEA in crescendo-TIA and progressive stroke Perioperative CEA risk of major stroke and death - TIA 6.5% - progressive stroke 17.0% c-TIA, 12 studies, 176 patients

Whom do we treat ? Stroke Symptoms Ischemic Stroke 80-85% Hemorrhagic Stroke 15-20% Cerebral Bleeding 2/3 Subarachnoidal Bleeding 1/3 Adapted from PA Scott and WG Barsan: Stroke, transient ischemic attack, and other central focal conditions. In: J Tintinalli: Emergency Medicine: A Comprehensive Study Guide; McGraw-Hill; 2000:14302/3

Stent & Suction Thrombectomy Solitaire® EV3 In the meanwhile at least 6 companies work on stent retriever systems ACI → Solitaire® 6 mm M1 segment → Solitaire® 4 mm M2 segment → Solitaire® 4 mm Vertebral/basilar artery → Solitaire® 4 mm Distal branches → Thrombolysis

Two Types of Occlusions Carotid-T occlusion Carotid bifurcation occlusion

Technique of Carotid Thrombectomy thrombus is crossed by guidewire and micro-catheter the tip of the micro-catheter is placed just beyond the occlusion the guidewire is exchanged for the Solitaire FR stent retriever the stent retriever is positioned at the level of the thrombus

Technique of Carotid Thrombectomy the micro-catheter is pulled back deploying the stent retriever blood flow may begin the carotid is blocked by balloon inflation after 4-5 min the Solitaire is pulled back slowly simultaneously an underpressure is produced by suction until the thrombus is caught in the aspiration catheter (50 ml syringe)

Carotis-T Occlusion Guidewire is exchanged for the stent retriever, microcatheter is pulled back to deploy the stent Guidewire & microcatheter cross the occlusion

J. B. m-52 Hemiplegic left side for 6 hrs CT Carotis-T Occlusion J. B. m-52 Hemiplegic left side for 6 hrs CT

J. B. m-52 Hemiplegic for 6 hrs Perfusion Carotis-T Occlusion J. B. m-52 Hemiplegic for 6 hrs Perfusion

J. B. m-52 Hemiplegic for 6 hrs CTA Carotis-T Occlusion J. B. m-52 Hemiplegic for 6 hrs CTA

J. B. m-52 Hemiplegic for 6 hrs Before and after TE Carotis-T Occlusion J. B. m-52 Hemiplegic for 6 hrs Before and after TE

J. B. m-52 Hemiplegic for 6 hrs CT n 24h Carotis-T Occlusion J. B. m-52 Hemiplegic for 6 hrs CT n 24h

Acute Stroke - Carotid-T Occlusion D.C. m-43 Acute Stroke - Normal CT findings

Acute Stroke - Carotid-T Occlusion D.C. m-43 hemiplegic ICA occlusion distal to the bifurcation After TE normal flow and full clinical recovery

Acute Stroke - Carotid-T Occlusion D.C. m-43 hemiplegic Control CT after 24h Clinically silent infarctions

Carotid Bifurcation Occlusion

Acute Stroke - Carotid Occlusion Perfusions study: still good blood volume Transit time Flow Blood volume M. O. m-64

Acute Stroke - Carotid Occlusion CEA? CAS preferrable in the acute situation* CT-Angio 4w after CAS & TE *Own experiences with more than 220 thrombectomies of carotid and cerebral arteries

Acute Stroke - Carotid Occlusion CEA? M. O. m-64 Residual thrombus after first TE - good result after second TE with the Solitaire Stent Retriever

Thrombectomy ICA D.E. f-62 Hemiplegic for 4 hours CTA right ICA & MCA occluded

Thrombectomy ICA Bifurcational disease or carotid-T occlusion ? D.E. f-62 Hemiplegic for 4 hours CAS & TE

Some ICA spasm after TE & CAS - MCA cleaned Thrombectomy ICA Some ICA spasm after TE & CAS - MCA cleaned D.E. f-62

Thrombektomie Solitaire® 6 mm

D.E. f-62 Hemiplegic for 4 hours No stroke demarcated Thrombectomy ICA D.E. f-62 Hemiplegic for 4 hours No stroke demarcated

E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs Thrombectomy ICA E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs

B.G. f-66 Aphasic and hemiplegic for 4 hrs Perfusion Study Thrombectomy ICA B.G. f-66 Aphasic and hemiplegic for 4 hrs Perfusion Study

B.G. f-66 Aphasic and hemiplegic for 4 hrs CTA Thrombectomy ICA B.G. f-66 Aphasic and hemiplegic for 4 hrs CTA

B.G. f-66 Aphasic and hemiplegic for 4 hrs Opacification of ICA stump Thrombectomy ICA B.G. f-66 Aphasic and hemiplegic for 4 hrs Opacification of ICA stump

B.G. f-66 Aphasic and hemiplegic for 4 hrs CT n 24 Std. Thrombectomy ICA B.G. f-66 Aphasic and hemiplegic for 4 hrs CT n 24 Std.

B.G. f-66 Aphasic and hemiplegic for 4 hrs MRT after 6 days Thrombectomy ICA B.G. f-66 Aphasic and hemiplegic for 4 hrs MRT after 6 days

Thrombectomy - Results all Patients* 228 100% Age 69±22 time window 3 - 7 Std technical success 222 97% - no infarction 64 28% - minor stroke 139 61% - major stroke 25 11% mortality (30 d) 5 2.2% *Own results 10-2010 - 09-2012

Thrombectomy Results ICA Patients* 56 100% Age 66±18 Time window 3 - 9 Std Technical success 55 98% with CAS 12 28% only TE 33 *Own results 10-2010 - 09-2012

Thrombectomy Results ICA Patients 56 100% No infarction 14 25% Minor stroke* 31 55% Major stroke** 9 10% ICB (NIH >4) 1 2% Own results 10-2010 - 09-2012 - *mRS <2; **mRS >2

Keep in mind ... Early recanalization improves the outcome dramatically Functional imaging is more important than the time window a short “Door to CT to Angio” time must be achieved there is no “I” team ... close cooperation is essential!