Day 2. Tuesday, 8 September
Local or general anesthesia?
The second day began with a cutting-edge topic session focused on another of the hot points still being debated in the ischemic stroke patient management: local or general anesthesia for endovascular recanalization? Questions remain, the debate was lively, the floor was given to the anesthesiologists Drs J. Fendeleur (Montpellier, France), J. Heijmans (Masstricht, Netherlands) and N. Bruder (Marseille, France). They provided us with excellent points concerning the advantages and disadvantages of each technique. A complete review of the literature looking at both approaches in ischemic stroke patient management was offered as well. In practice, whatever technique used, the anesthesiological management (e.g., high blood pressure maintenance) as well as a team approach with neurologists, neuroradiologists and anesthesiologists seem to be a central and “key” factor for good results.
First “live” case presentations and discussions
The Charleston, SC, USA neuroradiology team presented an interesting case of an ischemic stroke patient with left MCA occlusion and a severe neurological deficit, presenting with unusual perfusion-CT results with extended CBV abnormalities contrasting with moderate MTT abnormalities. However, from a technical point of view, this demonstrated successful proximal and distal aspirations which allowed for the recanalization of the MCA (TICI2a). A rich discussion between the expert panel and audience followed concerning potential complications during the aspiration procedure. They are mainly represented by distal embolisms due to thrombus fragmentation (in up to 15% of cases), and more rarely, arterial dissections and perforations.
The second case of the day came from Barcelona, Spain and the Val d’Hebron team. This involved a left ‘T’ carotid artery occlusion with severe clinical deficit. Extended ischemic lesions of the left anterior cerebral and middle cerebral arteries with severe perfusional impairement were present on perfusion-CT imaging. The recanalization by multiple stent retrievals under aspiration were successfully performed. The procedure realized under local anesthesia and mild conscious sedation allowed for the recanalization of the MCA territory, but without any clinical recovery. The Barcelona team shared with us an original technique of access in very tortuous arterial anatomy. It consisted of using stent retriever anchoring in a distal MCA branch (i.e., the M2 branch) and then going up with the intermediate catheter by using the anchored stent retriever as a support. Indeed, even if no correlation could be established with this endovascular maneuver, the long procedure ended with intraventricular and subarachnoid bleeding.
Silicon flow model case of the day
These case sessions were followed by the silicon flow model case of the day. This consisted of a right MCA M1 segment occlusion and recanalization by stent retriever. It was followed by a nicely prepared and very useful “tips and tricks” presentation presented by Dr J. Gralla (Bern, Switzerland). Different cases were shown covering various aspects of mechanical recanalization such as prevention of embolic events to previously unaffected territory (by proximal balloon occlusion or by distal intermediate aspiration catheter), access problems (by anchoring a stent retriever in a distal MCA branch and using it as support) and safety issues involved in endovascular recanalization procedures. An interesting point that should be kept in mind was highlighted regarding the difference between aspiration syringes and a continuous aspiration pump for thromboaspiration. The first technique results in a high negative pressure at the beginning of the aspiration that drops progressively at the end as the syringe fills; the second presents a continuous constant negative pressure.
SWIFT PRIME results and economic implications
Presented by Dr K. Lobotesis (London, United-Kingdom), this symposium reported on the latest results of the SWIFT PRIME trial concerning the economic impact of ischemic stroke and the cost-effectiveness of the SolitaireTM stent retriever. Despite the proven efficacy of stent retrievers for ischemic stroke treatment, faced with limited resources, long-term benefits and a cost-effectiveness evaluations were needed. For the first time in the world, in the framework of the SWIFT PRIME trial (Medtronic), a SolitaireTM cost-effectiveness analysis was performed in the UK National Health Services (about to be published). This demonstrated that the costs for SolitaireTM are negligible relative to the costs of managing functionally dependent patients. In addition, the associated cost savings are greatest in patients with higher functional dependence (mRS > 3). SolitaireTM + IV-tPA offers substantial cost savings versus IV-tPA alone by enabling 25% more patients to achieve functional independence.
Afternoon sessions with a “wake-up” stroke
The afternoon cases session began with a wake-up stroke reported by the Montpellier, France interventional neuroradiology team. Imaging showed a right MCA occlusion with a radio-clinical mismatch (NIHSS 14) and limited caudate nucleus DWI restriction. A mechanical thrombectomy under aspiration and proximal balloon occlusion allowed the complete recanalization (TICI3) after three passes and retrieval of two emboli in distal branch of the ACA and MCA. This case gave rise to a series of important questions on the clinical pertinence of FLAIR-negative stroke concerning safety of both mechanical thrombectomy and IV t-PA. An interesting debate on the relevance of NIHSS followed the case: Are NIHSS 8 with speech deficit and NIHSS 8 with massive hemiplegia comparable? Questions remain. An enhancement map (close to a CBV map) performed directly in the angiosuit was displayed. For the moment, the concept of perfusion assessment in the angiosuit remains at a research stage, but new technologies for this purpose are in development and should be available soon. A solution with triaxial catheters configuration for difficult access was nicely performed and described.
The following case was presented by the Bern, Switzerland interventional neuroradiology team. A wake-up ischemic stroke presenting as left hemiplegia on a ‘T’ carotid occlusion with secondary clinical worsening and perfusional mismatch was demonstrated by Perfusion CT. Discussions between the expert panel and audience concerned whether there was a need for limitations in patients selection for thrombectomy. Whereas the benefits of mechanical recanalization is now clear for all of us, decision making is still difficult and uncertain for elderly patients and extensive ischemic lesions. Indeed, the question of the benefits of treating or not treating patients with large extensive ischemic lesions was debated as well. Concerning the latter point, the question could be formulated as follows: What is the better outcome between mRS 6 and mRS 5? No one has the answer yet. Different strategies about avoiding anterior cerebral artery embolism, such as proximal occlusive balloon inflation associated with aspiration, or distal aspiration through an intermediate catheter were also discussed.
The Drs M. Goyal (Calgary, Canada) and M. Ribo (Barcelona, Spain) provided remarkable and relevant lectures concerning the pre-hospital management of the patient – one of the most important factor that determines the onset of treatment time. These lectures, based on the literature and the experience of big centers, underscored nicely the main issues in ischemic stroke patients management, which are different at the level of individuals and at the level of the population as a whole. Which organization at the societal level is the most efficient: to pick-up patients in the field which are most likely to have a proximal vessel occlusion (and so are eligible for endovascular treatment)? Which organization can steer the patients not likely to have proximal vessel occlusion to primary stroke centers instead of endovascular care centers? Could these two targets be made manageable by a unique solution?
The debate is open.
Many solutions based on local experiences were mentioned, which include real-time video smartphone assessment, mobile device applications and telemedecine systems. A very interesting roundtable discussion followed delineating some thematic thoughts and a working approach to improving prehospital management of these patients, such as centralization, optimization of the stroke workflow, training of paramedics, development of neuroprotection treatments.
Reviewing the trials
Dr W. Van Zwam (Maastricht, Netherlands) presented a complete and objective comparison analysis of the results of the main trials on endovascular treatment for ischemic stroke (MR CLEAN, SWIFT PRIME, ESCAPE, THRACE, REVASCAT). It was followed by an extraordinary roundtable discussion and exchange between the principle investigators of these trials and the audience. Dr W. Van Zwam nicely refreshed us on the different results that are now the basis of our treatment strategies. He also enlightened us on some of the critical methodological points of the different studies, explaining some of the difference between their results.
Running together for better Stroke Care!
The second day ended on a run for Stroke along the lovely beaches of Nice with the French Patient Association, “France AVC”. This was organized to support research and work in the field of stroke management.
Very well done and a big thank you to all participants for your spirit of solidarity and sportsmanship!
All the team of the SLICE organization wish you a good evening,
See you tomorrow!
Cyril Dargazanli, MD & Omer Eker, MD
The social media and report team