The day’s first topic – presented by three anesthesiologists, F. Rapido (Montpellier, France), W. Buhre (Maastricht, The Netherlands) and A. Maurice (Rennes, France) – discussed the important question of which anesthesia is best to use in stroke patients undergoing MT: General (GA) versus Conscious (or local) Sedation (CS). In order to answer this question, they presented the latest work on the subject, reviewing current literature and taking into account the advantages and disadvantages of each technique. To date, it is still not possible to say with certainty which method of anesthesiology is superior. In agreement with the current ASA guidelines, our speakers prefer CS over GA.
The second lecture was given by G.W. Albers (Stanford, CA, USA) regarding the future of advanced imaging in patient selection. He presented a unique and effective model of mobile stroke units which unquestionably should be more available. Inside these units, non-contrast rapid CT and rapid CT perfusion (CTP) can be performed, enabling the determination of intracerebral hemorrhage, stroke mimickers, infarct extension and even the presence of a mismatch – and thus invaluable in helping solve the common conflict of whether or not to transfer the patient directly to a CSC…and save precious time. Today, CTP can also be performed in the angiosuite, and allows for a rapid evaluation of the patient. G.W. Albers also gave the participants a peek into the DEFUSE 3 trial where stroke patients with MCA or ICA occlusion and salvageable tissue who were identified by CT perfusion or MRI were able to benefit from endovascular therapy within six to 16 hours. The trial was halted in progress by the DSMB for several reason, in part due to reviewed data showing demonstrating its efficacy. Unfortunately, but for understandable reasons, the results of this trial remain confidential, so we have a lot to look forward to…
In the third lecture of the day, M. Ribo (Barcelona, Spain) presented a study performed by his team at the Hospital Universitari Vall d’Hebron in Barcelona. Trying to reduce the “door to puncture” time, they allowed specifically chosen patients to pass directly from the ambulance to the angiosuite where a CT scan was performed. Patients were selected on the basis of whether they had a RACE score > 4 or NIHSS > 10 along with symptom onset < 6 hours. Pre-notification was given by the EMS to all relevant hospital teams, thus enabling them to prepare for receiving the patient and save valuable preparation time. By using this method, they managed to achieve their goal of further increasing efficiency and patient management.
Challenging clinical cases
The first case, presented by M. Ribo (Barcelona, Spain), was a complex case in which an impossible femoral access raised several questions regarding alternative access approaches, including:
- Which access, apart from femoral, could be considered as favorable?
- Can a carotid puncture be performed after IVT?
- Should blood pressure be lowered before carotid stabbing? What closure technique should be employed (manually vs. an angio-closing device)?
After finally gaining carotid access, a calcified lesion in a tortuous M1 was revealed. Classic techniques and a double-stenting technique failed to remove the stubborn clot. Finally, a coronary stent was deployed and recanalization was achieved.
The second case, with a Tandem occlusion, was introduced by P. Machi (Geneva, Switzerland). The question of whether to choose an antegrade or retrograde approach was considered with most of the audience (75%) agreeing with the presenter to treat the distal occlusion first. Among those who supported the antegrade approach, pre-thrombectomy angioplasty alone was suggested, raising the question of whether a distal protection device would be needed. Another point discussed concerned carotid stent insertion in the acute state, taking into account that there is no consensus regarding antiplatelet therapy after stenting with the constant threat of hemorrhagic transformation.
The third case, by A. Jadhav (Pittsburg, PA, USA) presented a case of a 58-year-old man who arrived to the hospital almost 11 hours after last being seen as normal and presenting with a primary NIHHS score of 1. Imaging demonstrated a near complete ICA occlusion as well as a decrease in the MCA flow. The first question was whether or not to take the patient immediately to the angiosuite despite his good condition; with most of the audience supporting a “wait and see” approach, going to the suite only in case of clinical deterioration. On the other hand, a common opinion was that since these cases always seem to deteriorate, it is better to treat them early, keeping in mind the risks involved in such a procedure. The point of encouraging the patient and his family to participate in the decision making process was also raised. In this present case, the decision was taken, based on the patient’s good clinical state, to delay the procedure until the following day. A distal protection device was inserted, after which aspiration through an intermediate catheter along the ICA was performed followed by stenting of the carotid artery, all of which were successfully accomplished. At this point the question of whether or not to continue and treat the filling defect in the MCA was raised, with most of the panel members in support of continuing to the MT despite the low NIHSS score. The panel also unanimously agreed that it would have been better to carry out the entire procedure the day before.
J-P. Desilles (Paris, France) presented the fourth case of a wake up stroke in a 90-year-old patient with a NIHSS score of 6. Imaging demonstrated a small core and M1 occlusion. Using the Direct Aspiration First Pass Technique (ADAPT), the MCA was successfully recanalized.
Recorded Thrombus Lab In Silicon Demonstration
Using the silicon model, G. Gascou (Montpellier, France) demonstrated a double stent-retriever technique for MT. Approaching a saddle-shaped bifurcation thrombus (sup. M2 and inf. M2 branches), he used a 9 Fr balloon guide catheter placed at the proximal ICA through which an intermediate 6 Fr catheter and a microcatheter were inserted. After deploying a stent in one of the two branches, the microcatheter was retrieved, navigated to the second branch and another stent was deployed. Both stents were then gently retrieved along with distal aspiration from the 6 Fr. The option of performing the procedure without using an intermediate catheter was also demonstrated with the insertion of two microcatheters, each within a different branch, opening the two stents and then retrieving them as one unit.
G.W. Albers (Stanford, CA, USA) discussed the difficulties in estimating core infarct and imaging interpretation during patient selection for MT. CTP, which is widely used for this purpose, has certain aberrations leading to an incorrect assessment and over-estimation of the ischemic core. It is also important to remember that CTP reflects the hemodynamics at the moment the scan is done (lacking historical information), therefore an ischemic core disappears after reperfusion or collateral recruitment. In the case of ASPECTS, low scores do not preclude salvageable tissue and it is not rare to get underestimation of an early ischemic core. These disadvantages decrease the method’s reliability and limit its use. The presenter suggested that a combination between the two imaging techniques might yet yield the most reliable results.
L. Pierot (Reims, France) presented a new generation thrombectomy device “ERIC” which offers fast clot integration, prevention of distal emboli, reduction of vascular trauma (limited contact points with the arterial wall) and improved navigability (using the Headway 0.017 inch microcatheter). So far, published data suggests that ERIC is feasible, safe and effective in acute ischemic stroke with LVO.
Live simulation of anesthesiology management
While simulating an MT, the presenters demonstrated the complexity of anesthesia while taking into account all the patient’s parameters. They demonstrated how to cope with unexpected challenges during the procedure that require anesthesiologists to act quickly and precisely in order to secure the patient’s well-being and enable continued catheterization with minimal distractions.
Major literature review
What should – or can – be done after six hours?
This question was debated by our panel of experts including T.G. Jovin (Pittsburg, PA, USA), R. Nogueira (Atlanta, GA, USA), W.V. Zwam (Maastricht, The Netherlands) and G.W. Albers (Stanford, CA, USA) leading to an interactive, interesting discussion concerning the DAWN trial and its ongoing results.
And the day ended … with a cocktail gathering at our hotel terrace overlooking the beautiful Mediterranean Sea – the perfect ending for a full and enriching day…
And now on to Day 3!
Shani AVNERY KALMANOVICH
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital
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