1. Cardiovascular Research Technology Conference (CRT 17)
Cerebro-Vascular Neurology Basics: Medical Therapy versus Intervention for Vascular Disease
Cardiovascular Research Technology Conference (CRT 17)
February 21, 2017
10:24AM – 10:36AM
Richard T. Benson, MD/PhD
Associate Director, NIH Stroke MWHC
Associate Professor of Clinical Neurology
Georgetown University Medical Center

2. Disclosures?
No Financial Disclosures!

3. Topics Extra-cranial carotid disease Intra-cranial arterial disease
Acute LVO of the anterior circulation

4. Carotid Endarterectomy
Three large studies have shown the benefit of CEA in symptomatic patients with >70% stenosis (NASCET, ECAT, VACSP). For those with moderate stenosis, 50 – 69% and symptoms, other factors e.g. co-morbid conditions, gender, and risk factors must be considered.
For patients with a severe (>70 stenosis), CEA has been shown to be beneficial in several studies. For patients with moderate (50 – 69%) stenosis, the treatment is not as clear and other factors must be taking into consideration.

5. Carotid Endarterectomy: Symptomatic stenosis
Barnett HJM et al., CMJ 2003

6. Carotid Endarterectomy: Asymptomatic stenosis
Barnett HJM et al., Arch Neurol 2000

7. AHA/ASA 2014 Guideline for the Prevention of Stroke in Patients with Stroke and TIA
1. For patients with TIA/IS within last 6 months and 70-90% stenosis, CEA is recommended (if the perioperative morbidity
mortality <6%).
2. For recent TIA/IS and 50-69% stenosis, CEA is recommended based on patient specific factors (same risk above)
3. When degree of stenosis <50% CEA and CAS are not recommended.
4. When indicated, revascularization should be within 2 weeks of index event (if small stroke and no hemorrhage)
5. CAS is indicated as a alternative to CEA based on patient specific factors, anatomy, and neck morphology

8. CEA vs CAS: (CREST Trial)
117 centers in the U.S. and Canada
2502 participants: (mean age = 69 years)
symptomatic and asymptomatic carotid stenoses
Funded by NIH/NINDS
More strokes in CAS group: 4.1% vs 2.3%
More MIs in CEA group: 2.3% vs 1.1%
Younger (<70 yo) did better with CAS
Older (≥70 yo) did better with CEA
1 yr follow-up: stroke had greater impact than MI on quality of life
CAS = stenting
Brott et al. NEJM May 26, 2010

9. SAMMPRIS NEJM 2011
BMT vs PTAS
1. Randomized multi-site study
% stenosis of intra-cranial vessel
(224 PTAS) patients
4. Dual anti-platelets for 3 mo in BMT
5. Wingspan stent
Results:
1. Risk of stroke high initially in PTAS
2. Risk in BMT group lower than expected

10. AHA/ASA 2014 Guideline for the Prevention of Stroke in Patients with Stroke and TIA
1. For patients with TIA/IS with 50-99% stenosis of a major intra-cranial artery ASA 325mg is recommended over warfarin.
2. For patients with TIA/IS within 30 days attributable to 70-99% stenosis of an intra-cranial artery, combination of ASA 325mg/Plavix 75mg for 90 days might be reasonable.
3. Stenting of intra-cranial arteries is not recommended

11. Acute Ischemic Stroke: Major thrombolytic Landmarks
Lower rates of early recanalization and worse outcomes in patients with large vessel occlusion with IV r-tPA.

12. Acute Treatment – IA Therapy
Improved clot retrieval devices:
Stentrievers

13. Acute Ischemic Stroke: Major Endovascular Landmarks
MR CLEAN (N Engl J Med 2015;372:11-20)
ESCAPE (N Engl J Med 2015;372: )
EXTEND IA (N Engl J Med 2015;372: )
SWIFT PRIME (N Engl J Med doi: /NEJMoa )
REVASCAT (N Engl J Med doi /NEJMoa )

14. (Grotta and Hacke, Stroke:June 2015)

15. (Grotta and Hacke, Stroke:June 2015)

16. Acute Ischemic Stroke: Major Endovascular Landmarks
Take home points:
1. IAT should be considered in:
Pts with distal ICA/M1 occlusions
Relatively normal CT (suggesting good collaterals)
Significant neurological deficit (NIHSS ≥6)
Can have recanalization in <6 hours
(Grotta and Hacke, Stroke:June 2015)

17. Neuro-vascular Interventions
Conclusion:
Extra-cranial carotid disease
CEA
CAS
Embolectomy
BMT
Intra-cranial disease