1. European Stroke intervention Guidelines ESMINT/ESO/ESNR/EAN WLNC 2015
C. Cognard
University Hospital of Toulouse
France

3. Recent burning news October 2014, World Stroke Conference (Istanbul):
Mr Clean +
Nov. 2014, ESO- Karolinska stroke update conference,
ESO, ESMINT/ESNR guidelines meeting
Feb. 2015, International Stroke conference, Nashville:
Escape, Extend IA, Swift Prime +
Feb. 2015, Stroke winter school
Apr. 2015, European Stroke Organization conference (Glasgow)
Thrace and Revascat +

4. mRs 2 at 3M
MT / IV in all studies
Odds ratio: 2.29

5. Mortality
MT / IV in all studies
Odds ratio: 0.74

6. All symptomatic ICHs
MT / IV in all studies
Odds ratio: 1.14

7. Writing recommendations is doing diplomacy
Need to obtain a common agreement

8. Treatment recommendations
Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to 6h after onset
What means “up to 6h after onset” ?
Angio-room ?
Groin?
Recanalization ?

9. Studies Design/Results
Onset MT
Onset IV
Groin
Delay
IV/Groin
Mr Clean
< 6 h
1h25
4h20
2h55
Escape
< 12 h
1h50
3h05
1h15
Extend IA
2h07
3h30
1h23
Swift Prime
3H04
1h14
Revascat
< 8 h
1h57
4h29
2h32
Thrace
4h15
1h43
Therapy
< 5 h
1h48
3h46
1h58

10. Onset to reperfusion in Mr Clean
Median 332 mn (IQR )
1.5% < 3h
22% from 3 to 4.5h
40% from 4.5 to 6h
37% > 6h
MT/IV Absolute risk difference on mRS 0-2
At 2h: 33 %
At 6h: 6.5%
7% decrease per hour delay

11. Thrombectomy is recommended
up to 6h after onset

12. Treatment recommendations
Thrombectomy is recommended for LVO Stroke of the anterior circulation in addition to IV up to 6h after onset
What means a “LVO of the anterior circulation”?

13. Should we treat stroke with ICA occlusion / Severe stenosis?
LVO ?
Should we treat stroke with ICA occlusion / Severe stenosis?

14. Studies Results Mr Clean Escape Extend IA Swift Prime Revascat Thrace
ICA/M1/M2
Cervical
ICA
Mr Clean
28/62/8 %
32 %
Escape
28/68/4%
12.7 %
Extend IA
31/57/11% -
Swift Prime
18/68/14 %
4.3%
Revascat
25/85/10%
Thrace
15/85%
BA: 0.5%
Therapy
33/56/11 %

15. MR Clean

16. Should we treat M2 occlusion?
LVO ?
Should we treat M2 occlusion?

17. Studies Results Mr Clean Escape Extend IA Swift Prime Revascat Thrace
ICA/M1/M2
Mr Clean
28 / 62 / 8 %
Escape
28 / 68 / 4 %
Extend IA
31 / 57 / 11%
Swift Prime
18 / 68 / 14 %
Revascat
25 / 85 / 10 %
Thrace
15 / 85 / 0 %
Therapy
33 / 56 / 11 %

18. Treatment recommendations
One message
Save time

19. Treatment recommendations
Evidence only concerns stent-retrievers
Door is open to other device/technique
But need evaluation

20. Treatment recommendations
Thrombectomy is recommended as first line treatment in case IV is contraindicated

21. Studies Design Mr Clean Escape Extend IA Swift Prime Revascat ThraceIV
Other
Mr Clean
89%
Escape
72.7%
Extend IA
100%
Swift Prime
Revascat
68%
Failure IV 30 min
Thrace
Failure IV 60 min
Therapy

22. Treatment recommendations
Thrombectomy can be performed in the posterior circulation
But NO Evidence

23. Studies Results Mr Clean Escape Extend IA Swift Prime Revascat Thrace
ICA/M1/M2
Cervical
ICA
Mr Clean
28/62/8 %
32 %
Escape
28/68/4%
12.7 %
Extend IA
31/57/11% -
Swift Prime
18/68/14 %
4.3%
Revascat
25/85/10%
Thrace
15/85%
BA: 0.5%
Therapy
33/56/11 %

24. Treatment recommendations
Thrombectomy must be done by comprehensive neurovascular team

25. Treatment recommendations
And by highly specialized Neuro-interventionists
What are the National / International requirements ?

26. Treatment recommendations
There is no Evidence

27. GA versus CS Mr Clean Escape Extend IA Swift Prime Revascat Thrace
37.8%
Escape
9.1%
Extend IA
36%
Swift Prime
37.1%
Revascat
6.7%
Thrace
50%
Therapy

28. Impact of GA on TT effect in Mr Clean Common adjusted OR
Effect of GA/non GA on 3M shift mRS
Non GA vs Control: 2.13 R (95% CI, )
GA vs Control: (95% CI, )
Effect of GA/non GA on 3M mRS 0 -2
Non GA vs Control: (95% CI, )
GA vs Control: (95% CI, )

29. A randomize Trial One answer to one question
Statistical massage to answer a not predefined question should not be done

30. Need for randomized Trials design to answer the question GA/CS

31. No thrombectomy if no LVO
Patient Selection
No thrombectomy if no LVO

32. Patient Selection Do we need to assess the LVO by imaging
To decide to transfert the patient to a thrombectomy center ?
But lot of patient un-necessarily transferred for a deep hematoma

33. Patient Selection The major question!
Which patient should not receive thrombectomy due to a too large stroke?

34. Studies Design Mr Clean Escape Extend IA Swift Prime Revascat Thrace
NIHSS
Design
IV/MT
ASPECT
Other imaging
Mr Clean
> 1
18/17
all
9/9
Escape
> 5
17/16
Multiphase CTA
Extend IA
0-42
13/17 -
« Rapid » mismatch:
Swift Prime
8-29
17/17
Revascat
≥ 6
> 6 CT
> 5MR 7
Thrace
17/18
> 6
Therapy
> 8
7.5

35. MR Clean

36. MR Clean

37. On Which imaging criteria we should refuse to perform a thrombolysis ?
And why?
Is thrombectomy dangerous?
Or just futile

38. Volume of diffusion by automated software: Yes but which volume?
Patient Selection
1/3 MCA: No
ASPECT: No
Volume of diffusion by automated software: Yes but which volume?
Rapid mismatch ?

39. Patient Selection
No age limit
But be human!

40. MR Clean

41. Recommendations for implementation, registries and further trial
We need to do politics

43. Recommendations for implementation, registries and further trial

44. Recommendations for implementation, registries and further trial
RCTs for:
-Posterior circulation ?
Stroke imaging ?
IV+MT versus MT alone +/- IV +
GA versus CS +++
> 6h +++
New devices +++

45. After 6 H? Down study

46. GA/CS?

47. Recommendations for implementation, registries and further trial
A national consecutive registry in every country

48. The routine practice in Toulouse
We have treated in the last week:
A 91 YO Woman
A Patient with a NIHSS 2
Lot of patients with M2 occlusion
Lot of patients with ICA occlusion
No patient > 6h

49. Thanks