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European Stroke intervention Guidelines
ESMINT/ESO/ESNR/EAN
WLNC 2015
C. CognardUniversity Hospital of Toulouse
France
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
ESO, ESMINT/ESNR guidelines meeting
• Apr. 2015, European Stroke Organization conference (Glasgow)
Thrace and Revascat +
mRs 2 at 3MMT / IV in all studies
Odds ratio: 2.29
MortalityMT / IV in all studies
Odds ratio: 0.74
All symptomatic ICHsMT / IV in all studies
Odds ratio: 1.14
Writing recommendations is doing diplomacy
Need to obtain a common agreement
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 ?
Onset MT OnsetIV
OnsetGroin
DelayIV/Groin
Mr Clean < 6 h 1h25 4h20 2h55
Escape < 12 h 1h50 3h05 1h15
Extend IA < 6 h 2h07 3h30 1h23
Swift Prime < 6 h 1h50 3H04 1h14
Revascat < 8 h 1h57 4h29 2h32
Thrace < 6 h 2h32 4h15 1h43
Therapy < 5 h 1h48 3h46 1h58
Studies Design/Results
Onset to reperfusion in Mr Clean
• Median 332 mn (IQR 279-394)– 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
Thrombectomy is recommended up to 6h after onset
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”?
LVO ?
Should we treat stroke with ICA occlusion / Severe stenosis?
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 % -
Studies Results
MR Clean
LVO ?
Should we treat M2 occlusion?
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 %
Studies Results
Treatment recommendations
One messageSave time
Treatment recommendations
Evidence only concerns stent-retrievers
Door is open to other device/technique
But need evaluation
Treatment recommendations
Thrombectomy is recommended as first line treatment in case IV is
contraindicated
IV Other
Mr Clean 89%
Escape 72.7%
Extend IA 100%
Swift Prime 100%
Revascat 68% Failure IV 30 min
Thrace 100% Failure IV 60 min
Therapy 100%
Studies Design
Treatment recommendations
Thrombectomy can be performed in the posterior circulation
But NO Evidence
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 % -
Studies Results
Treatment recommendations
Thrombectomy must be done by comprehensive neurovascular team
Treatment recommendations
And by highly specialized Neuro-interventionists
What are the National / International requirements ?
Treatment recommendations
There is no Evidence
% GA
Mr Clean 37.8%
Escape 9.1%
Extend IA 36%
Swift Prime 37.1%
Revascat 6.7%
Thrace 50%
Therapy
GA versus CS
Impact of GA on TT effect in Mr CleanCommon adjusted OR
• Effect of GA/non GA on 3M shift mRS– Non GA vs Control: 2.13 R (95% CI, 1.46-3.11)– GA vs Control: 1.09 (95% CI, 0.69-1.71)
• Effect of GA/non GA on 3M mRS 0 -2– Non GA vs Control: 2.79 (95% CI, 1.70-4.59)– GA vs Control: 1.09 (95% CI, 0.56-2.12)
A randomize Trial
• One answer to one question
• Statistical massage to answer a not predefined question should not be done
Need for randomized Trials design to answer the question GA/CS
Patient Selection
No thrombectomy if no LVO
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
Patient Selection
The major question!
Which patient should not receive
thrombectomy due to a too large stroke?
NIHSSDesign
NIHSSIV/MT
ASPECTDesign
ASPECTIV/MT
Other imaging
Mr Clean > 1 18/17 all 9/9
Escape > 5 17/16 > 5 9/9 Multiphase CTA
Extend IA 0-42 13/17 - « Rapid » mismatch:
Swift Prime 8-29 17/17 9/9
Revascat ≥ 6 17/17 > 6 CT> 5MR
7
Thrace 10 - 25 17/18 > 6
Therapy > 8 18/17 7.5
Studies Design
MR Clean
MR Clean
On Which imaging criteria we should refuse to perform a thrombolysis ?
And why?
Is thrombectomy dangerous?
Or just futile
Patient Selection
- 1/3 MCA: No
- ASPECT: No
- Volume of diffusion by automated software: Yes but which volume?
- Rapid mismatch ?
Patient Selection
No age limit
But be human!
MR Clean
Recommendations for implementation, registries and further trial
We need to do politics
Recommendations for implementation, registries and further trial
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 +++
After 6 H?
Down study
GA/CS?
Recommendations for implementation, registries and further trial
A national consecutive registry in every country
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
Thanks
