1. Acute Stroke Management
SOFIA - BEC 2012
Acute Stroke Management
K. Mathias
Department of Radiology
Klinikum Dortmund / Germany

2. 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

3. 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

4. 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

5. When the stroke occurs in the city of Dortmund itself
we have the patient in the hospital within 30 min !

6. 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 ?

7. CT must tell us ... dense media sign ischemia, no infarction
large perfusion defect = tissue at risk
I.K. f-85y

8. Time Window ... studies on i.v. thrombolysis teached us:
6 hours too often ICB
3 hours too few patients
4.5 hours optimum, but ...

9. 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 !

10. ... 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

11. Thrombectomy - MCA M1 segment →Solitaire® 4 mm
Solitaire® EV3
M1 segment →Solitaire® 4 mm
M2 segment →Solitaire® 4 mm
more distal branches → thrombolysis

12. 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

13. Thrombectomy MCA
A. C. St. f-73 Hemiplegic for 4 hrs CTA: MCA occlusion
Perfusion study: underperfused anterior mca territory

14. Thrombectomy MCA A. C. St. f-73 Hemiplegic for 4 hrs
Angio: MCA occlusion - one posterior branch preserved Solitaire® 4 mm

15. Thrombectomy MCA
Solitaire® 4 mm
A. C. St. f-73

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Thrombectomy Results patients* 228 100% age 69±22
time window hrs
technical success %
- no infarction %
- minor stroke %
- major stroke %
mortality (30d) %
*Own results

23. 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 !

24. We have efficient techniques to prevent strokes today ...
... but we have to organize
the logistics!