Morphological and clinical results of invasive intra-arterial recanalization in the event of an acute stroke I Gubucz, Z Berentei, M Marosfői, C Óváry, D Varga, N Szegedi, I Szikora National Neuroscience Institute, Budapest, Hungary

Background: Intravenous recanalization In case of major arterial occlusion Low recanalization rate: % High frequency of early reocclusion: 34% vs IAT17% Neurology 2002;59:862, AJNR 2004;25:322 Narrow therapeutic time window

Purpose To evaluate the morphological and clinical efficacy of intra-arterial recanalisation techniques furthermore the safety of the procedure Applied within a 6 hrs time window With or without iv therapy In a stroke center providing 24 hrs stroke service including intra-arterial procedures

Methods and materials: Patient selection ICA-TM1 BA major vessel occlusion within 6 hours time window

<3 (4.5) hours Major vessel occlusion IVT mg/kg rtPA successful unsuccessful 3 (4.5) -6 hours Major vessel occlusion IAT and/ MT Extended time window at basilar occlusion IAT and/ MT Extended time window at basilar occlusion Methods and materials: Therapeutic algorithm

Methods and materials: Endpoints Collateral flow Recanalization rate Early clinical outcome: ≥4 points improvement on NIHSS within 24 hrs Late clinical outcome: Mortality and functional outcome after 6 months Safety: Intracerebral bleeding and procedural complications

Pretreatment evaluation of DSA: Collateral flow R.T. Higashida, at al: Trial design and reporting standards for IA cerebral thrombolyis for acute ischemic stroke. Stroke. 2003;34:109

Posttreatment evaluation of DSA Recanalization (TICI) T. Tomsic, and the IMS-II investigators: Revascularization results in the International Management of Stroke II Trial. AJNR. 2008; 29(3):582

Classifaction of outcomes and safety Early outcome: 24 hrs ≥4 points improvement on NIHSS mRS=0-2: GOOD mRS=6: DEATH Bleeding Stroke, 2001; 32:1330 Procedural complications Safety HI-1 HI-2 PH-1PH-2 Late outcome: 6 months

Result: Patient cohort January 2007 – May 2010 Total: 77 patients 6-month follow up: 68 patients Retrospective, single arm study Initial NIHSS18.8 ± 5.2 (7-30) NIHSS after 24 hrs15.3 ± 8.3 (0-30) Treatment started3.9 ± 1.7 ( ) Treatment finished6.19 ± 1.5 ( )

Results: Treatment techniques Mean No of modalities/case 3.25± 1.55 (1-6) 1. IVT 50% 2. IAT 84% 3. MT 97% Thrombus fragmentation with balloon 15% with guide wire 82% Embolectomy Thrombectomy & Thrombaspiration 71% Stents 20%

Results ΔNIHSS≥4Recanalization6-month outcomeComlications 44%TICI0: 12%mRS≤2: 35%PH2: 11% TICI1: 10%mRS=3-5: 29% Procedural ̴ : 0 TICI2A: 25%Death: 36% TICI2B: 38% TICI3: 15% TICI2-3: 78%!

Deaths after Six months mortality: 25 pts (36%) Recanalization p=0.033 Collaterals p=0.001 ΔNIHSS≥4/24h p=0.000 Age (years) p=0.120 TICI0: 62.5%G0: 0%Yes: 4%17-50: 28% TICI1: 43%G1: 68%No: 96%51-74: 33% TICI2A: 53%G2: 31%≥75: 64% TICI2B: 31%G3: 11% TICI3: 0%G4:- Chi-square test

mRS≥2 after 6 months: 24 pts (35%) Recanalization p=0.001 Collaterals p=0.000 ΔNIHSS≥4/24h p=0.000 Age (years) p=0.082 TICI0: 12.5%G0: 50%Yes: 92%17-50: 55.5% TICI1: 0%G1: 4.5%No: 8%51-74: 31% TICI2A: 23%G2: 30.8%≥75: 18% TICI2B: 38.5%G3: 78% TICI3: 90%G4:- Chi-square test

Conclusion Both early and late outcomes are strongly related to: collateral flow AND recanalization rate At least TICI2B reperfusion in the affected area is needed for better outcome Only TICI2B-3 recanalization means SUCCESSFUL Clinacal Outcome