Advanced Treatment Options for Stroke Patients Vickie Gordon PhD, ACNP-BC, CNRN

Stroke Stroke is the rapidly developing loss of brain function(s) due to interruption in the blood supply to the brain and can result in permanent neurological damage. Two Types –Ischemic Stroke –Hemorrhagic Stroke

Ischemic Stroke Occlusion (50%) –Large vessel (ICA) –Branch (MCA) –Perforator (lacunar) Embolization (25%) –Intra/Extracranial –Cardiac Cryptogenic (25%)

Limitations of IV rtPA Generalizability –4% utilization of rtPA –25% present within 3 hours: 29% eligible Major strokes are difficult –Baseline NIHSS >10 or dense MCA sign predicted poor clinical outcome –Large vessel recanalization rate low. Increased risk of sICH with larger strokes

Recanalization Acute Ischemic Stroke: Endovascular Treatment Contra indication to IV rtPA No change in NIHSS score one hour following administration of IV rtPA 3 hour treatment window has expired but less than 10 hours Severe neurological deficits (NIHSS>16) –Evidence of major cervical or intracranial vessel occlusion

Recanalization Acute Ischemic Stroke: Endovascular Treatment Treatment within 8 hours; longer in some cases (posterior circulation). IV/IA rtPA Merci Retrieval Device (FDA approved) Penumbra Aspiration Device (FDA approved)

Endovascular Treatment Femoral or radial access Series of catheters –Sheath –Guide Catheter –Micro catheter Wire navigation

Biplane and 3D reconstruction

Intra-Arterial rtPA Treatment rtPA into the thrombus

Mechanical Embolectomy Merci Device

Mechanical Embolectomy Penumbra

Extracranial Stenting Extracranial Carotid Artery Stenosis Distal Protection

Intracranial Stenting ICAD accounts for 10-29% of brain ischemic events Symptomatic ICAD 25% of patients with 70-99% stenosis had a stroke within 2 years Balloon angioplasty alone not effective

Intracranial Stenting Gateway Balloon and Wingspan Intracranial Stent Balloon Angioplasty Stent Placement

New Strategies Thrombolytic –rtPA alternatives –IIb/IIIa inhibitors –TCD enhanced thrombolysis Neuroprotective –Mild Hypothermia –Albumin –Drug Therapy Endovascular –EKOS (ultrasound enhanced thrombolysis –Neuroflo (perfusion augmentation) –Stent Retriever

Reperfusion: Neuroflo Device

EKOS Neurowave

Etiology of Hemorrhagic Stroke

Intracranial Aneurysm Rupture Treatment options –Surgical clipping –Endovascular embolization (coiling) Goal is to exclude the aneurysm from the cerebral circulation and prevent rupture or re rupture while not producing adverse neurological outcomes.

Aneurysm Treatment Coil Embolization –Platinum coils –Platinum alloy –Microfilaments Stent Placement –Adjunctive to coil placement Balloon Assist Polymer Embolization

Coil Devices Diameter Length Shape Tensile strength

Types of Coils

Coil Embolization Balloon-assisted –Temporary inflation of the balloon in the parent artery during coil positioning. Advantage no permanent device left in artery. Disadvantage: temporary occlusion with each coil. Stent-assisted –Deployment in the parent artery acts as a scaffold for the coils. Advantage: no temporary occlusion. Disadvantage: requires anti platelet therapy.

Aneurysm Treatment/Balloon Assist

Aneurysm Treatment/Stent-Coil

Aneurysm Treatment/Polymer Embolization

AVM treatment

Intraparenchymal Hemorrhage Treatment

Clinical Management: Preprocedure Peripheral Pulse check Baseline neurological check Baseline vital signs Baseline Lab results Baseline ACT Anti-platelet therapy (plavix, aspirin, aggrenox) Contrast allergy pre- treatment (Benadryl, Prednisone, hydrocortisone) 2 IV lines (all interventional patients) Maintaining immobility Rapid recovery after anesthesia –Neuro-protection Management of anticoagulation Manipulating systolic blood pressure –Avoid nitrates

Clinical management: Postprocedure Neurological check Vital signs Monitor Lab results Anti-platelet therapy (plavix, aspirin, aggrenox) Peripheral Pulse check

Complications of Endovascular Treatment Morbidity and Mortality of endovascular treatment %. Cerebral Infarction Cerebral Hemorrhage Cerebral Edema

Cerebral Infarction Thrombus formation –Intra procedure –Post procedure Parent artery dissection Parent artery occlusion –Coil migration –Stent migration Cerebral vasospasm Vessel Re-stenosis

Cerebral Hemorrhage Aneurysm rupture AVM rupture Ischemic reperfusion injury –Hemorrhage –Contrast extravasations Parent artery perforation

Cerebral Edema Peaks 3 to 5 days following injury Increased risk with large hemorrhage or hemispheric infarcts Increased risk of brain herniation.

Impact of Cerebral Infarction, Edema and Hemorrhage

Thank you Questions