Building the future together in stroke care – Day 3

An active – and interactive – discussion

The day began with a lively debate concerning a new therapeutic aspiration algorithm used as a first pass. V. Costalat (Montpellier, France) presented his personal experience favoring this technique, especially in the case of proximal and shorter clots. Not only time saving, but with less impact on the vessel wall as compared to a stent retriever, he was convinced that this is a technique that should be kept in mind. In certain instances, as in case of a long clot, we need to repeat the action several times, and it becomes clear that this technique should not be used “automatically”, especially when dealing with longer thrombi.

M. Piotin (Paris, France) presented differences in the efficacy and safety between ADAPT and SR, reviewing the different meta-analysis regarding this topic and illustrating that they all showed the same results:

  • Faster recanalization can be achieved using the ADAPT technique.
  • Similar clinical outcomes were seen for both techniques.
  • Concerning safety – in case of ADAPT there is less EST than with SRT תמונה
  • ADAPT is much cheaper.

The day continued with B. Lapergue (Suresnes, France) who performed an extensive literature review looking at trials in which patients were treated with the ADAP technique alone, without control groups. For instance, according to the ASTER trial, there is no significant difference between the two techniques, a fact which the speaker found to be true in his own institutional experience. No trial regarding posterior circulation was published.

J Mocco (New York, NY, USA) introduced the most commonly used approach in the USA, presenting the COMPASS trial, whose results are soon to be published and which was designed to demonstrate the non-inferiority of the ADAPT vs. SR.

Based on the personal experiences of our panelists, the general consensus was that, despite the lack of supporting major trials, the ADAPT technique can be used in certain cases.

O. Gjertsen (Oslo, Norway) presented a case of a massive sinus vein thrombosis that was treated by MT after failed medical treatment. He spoke about the complexity of the procedure and about the lack of current data regarding this situation.
In the third lecture of the day, A. Cargliano presented his institutional experience using the ADAPT technique for the first pass. In treating 30 patients, his hospital achieved an 83% recanalization rate only using ADAPT (TICI ≥ 2b-3) and a 92% recanalization rates after the use of an adjunctive device. They had no embolic complications or dissections.

A review of the literature concerning ADAPT and SR MT was presented by I. Vallone in which he shared his hospital’s experience with the audience.
V. Costalat introduced the IN EXTREMIS trial that includes two groups of patients (in order to avoid under treatment). In this trial, the first group was composed of patients who are not candidates for MT due to low NIHSS score, while the second group was composed of patients who are not candidates for MT due to highly severe strokes (ASPECTS 0-5). Only patients exhibiting negative stroke evolution with persistent LVO and low NIHSS and who were treated with conservative treatment were presented. The trial was designed based on the assumption (supported by very few smaller trials) that those patients who had been “automatically” ruled out for MT could have benefited from this treatment as well.

C. Dargazanli (Montpellier, France) presented a literature review looking at thrombus pathology and its influence on MT. He discussed the different pathological patterns of clots and their mechanical properties, with the goal of trying to understand whether different thrombi characteristics lead to different thrombi behavior, and thus influence MT. In the second part of his lecture, he focused on the potential correlation between thrombus etiology and stroke etiology.

J.M. Olivot (Toulouse, France) spoke on secondary stroke prevention, presenting current guidelines for the treatment of patients with AF. He also discussed the subject of preventing ICA stent occlusion, focusing on the fact that ischemic events in patients with symptomatic carotids tend to reoccur.

P.A. Brouwer (Stockholm, Sweden) told the audience that “the only reason for not giving lysis is the potential risk of hematoma” and went on to challenge the many restrictions that prevent us from giving IVT, presenting his literature-supported approach to these limitations. As you might imagine, this led to an interesting and passionate debate.

Challenging clinical cases

The first case was from T.G. Jovin (Pittsburgh, PA. USA) involved a young patient with LT-sided symptoms and a RACE score = 5. He was taken to a nearby, local hospital where a CT scan showed a hyper-dense MCA. Using a telemedicine set-up for patient evaluation and imaging analyses, it was decided to transfer the patient to the University of Pittsburgh Medical Center (UPMC) located 250 km away. During the transportation he received IVT. Upon arrival at UPMC, the patient was transferred directly to the angiosuite where T.G. Jovin, after a tandem occlusion was determined, chose the retrograde approach with manual aspiration of the intracerebral (M1) clot through an intermediate catheter.

The challenge of dealing with a highly uncomfortable patient opened the debate on GA. One of the participating anesthesiologists argued that by using a correct anesthesiologic protocol it is possible to control the patient’s pain and consciousness, allow for a safer procedure and clinical evaluation, while at the same time decreasing the patient’s suffering. After recanalizing the M1, the decision was taken to continue and try to open the distal M3, but unfortunately this was not possible. Participants raised the question about the influence of the initial IVT on this type of distal occlusion. Due to mechanical manipulations, there was a near complete opening of the ICA and no further treatment was taken at that time (with a plan for future stenting). However, the next day, the ICA occulted again. Using manual aspiration through an intermediate catheter, the vessel was recanalized and a stent introduced.

V. Costalat presented the second case of a case 90-year-old patient with symptomatic severe carotid stenosis where CEA was contraindicated (the problem of octogenarians and general anesthesia, as well as a high bifurcation). Three different flow patterns were shown that might rise during a carotid occlusion test, clarifying the different working techniques that each pattern has. After atropine administration, V. Costalat performed an angioplasty and stent placement. A single antiplatelet agent combined with warfarin (due to AF) was the treatment of choice for this specific patient.

The day’s third case, presented by M. Ribo (Barcelona, Spain) was a tandem occlusion in an 84-year-old patient.

Sponsored symposium

J. Mocco (New York, NY, USA) spoke about the main points of the VITAL study.
J. Van Der Merwe (Germany) presented the “Angels Initiative”, a unique healthcare initiative to improve acute stroke care across Europe. The Angels Initiative aims to build a community of at least 1,500 stroke centers and stroke ready hospitals across the continent over the next three years in order to improve acute stroke care. These improvements in stroke care could save thousands of lives and prevent disabilities for hundred thousands of people throughout Europe.

Recorded Thrombus Lab In Silicon Demonstration

Dealing with a distal occlusion is challenging. It is not rare for us to observe a collateral thrombus following proximal thrombectomy. G. Gascou (Montpellier, France) presented a unique technique for this kind of thrombi when it occurs in the anterior circulation. After gently adhering a 3 MAX catheter to the proximal part of the thrombus (which was located at A2/A3 segment), he removed the valve that was connected to the proximal part of the catheter and connected it to a mechanical pump. Then, he pushed the catheter 2 mm forward into the clot, waited for 30-60 seconds and then slowly retrieved. If there was no blood reflux after retrieving the 3 MAX catheter, it is important not to forget to perform aspiration of the BGC! The clot might be there!

Around the table talk

A fascinating discussion involved E. Abergil (Montpellier, France) who shared his personal experience of deciding move from being an interventional cardiologist to a neuro-interventionalist.

A fitting conclusion to a very full day….

 

Shany AVNERY KALMANOVICH, Cyril DARGAZANLI and Pierre-Henri LEFÈVRE

Shani AVNERY KALMANOVICH
Neurologist
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital

 

Read the Day 1 report
Read the Day 2 report
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