Grysiewicz ECI

7/17/2019 Grysiewicz ECI

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Beyond the Basics ofStroke Evaluation

Rebbeca Grysiewicz, DODirector, Comrehensive Stroke Center

Beaumont !ealth System" Royal Oak



Disclosures

#one



Ob$ectives

Discuss brief overview of stroke eidemiolo%y

Review endovascular reerfusion theray udates

&nalyze the role of stroke mobile units



Durin% a stroke '(,)))neurons die er second*



+he brain a%es '- years each hourwithout treatment durin% an ischemicstroke



Eidemiolo%y

&nnually, ./ million eole worldwide suffer a stroke

One"third of these individuals die and another one" third are left ermanentlydisabled

+he 0orld !ealth Or%anization 10!O2 estimates that a stroke occurs every /seconds



Eidemiolo%y

3n the 4nited States, aro5imately 67/,))) eole have a new or recurrentstroke each year

&bout -)),))) are new strokes and .7/,))) are recurrent strokes

& stroke occurs aro5imately every 8) seconds, which is (.-) strokes er day



Eidemiolo%y

3n the 4S, stroke is the rimary cause of lon% term disability with anestimated -/ million survivors amon% adults a%e () and older 1(- millionmales and '7 million females2

+he estimated ()./ direct and indirect cost of stroke is 97/ billion



Eidemiolo%y

Stroke mortality e5tends beyond ./),))) eole annually

Stroke is now the fifth leadin% cause of death in the 4S, and the secondleadin% cause of death %lobally

Stroke accounts for nearly . out of every .- deaths in the 4S andaro5imately .): of all deaths worldwide



Eidemiolo%y

Stroke can either be ischemic 1an occlusion of a blood vessel2 or hemorrha%ic1a ruture of a blood vessel2

!emorrha%ic strokes include intracerebral hemorrha%e 13C!2 andsubarachnoid hemorrha%e 1S&!2



Eidemiolo%y



Eidemiolo%y

Of all strokes in the 4S, ;6 ercent are ischemic, .) ercent are 3C! and 'ercent are S&!

3schemic strokes are further classified into subtyes accordin% to themechanism of in$ury



<athohysiolo%y

+he de%ree of dama%e is deendent on duration of ischemia and de%ree ofcollateral flow

#ormal cerebral blood flow is %reater than /)m=>.))m%>min, but if bloodflow is decreased to less than .)m=>.))m%>min, irreversible neuronal deathoccurs ?uickly



<athohysiolo%y

Blood flow between .. and () m=>.))m%>min is thou%ht to reresent theischemic enumbra

+his is an area of neurons that are ischemic, but still viable if blood flow isrestored

+he ischemic enumbra is the tar%et of most acute stroke interventions inwhich recanalization of a vessel should theoretically restore erfusion to theenumbra



<athohysiolo%y



&cute mana%ement@ thrombolysis

3A thrombolysis with recombinant tissue lasmino%en activator 1rt"<&2 is theonly D& aroved dru% treatment for acute ischemic stroke

Endo%enous tissue"lamino%en activators convert lasmino%en to lasmin, anenzyme that catalyzes fibrin breakdown

ibrinolysis is stron%ly enhanced by rt"<&







Double blinded lacebo"controlled trial with -(8 atients randomized to 3A rt"<& or lacebo

<atients who received rt"<& within ' hours had more favorable outcomes andwere '): more likely to have minimal or no disability at ' months 1odds ratio.6, 7/: C3 .( to (-2






Only a select %rou of atients are eli%ible to received rt"<&

+he ma$or adverse affect of rt"<& is hemorrha%e

+he symtomatic intracranial hemorrha%e rate in the #3#DS trial was -8:

Symtomatic 3C! was seen rimarily from hemorrha%ic transformation of theischemic infarct




&n additional landmark study was the Euroean Cooerative &cute StrokeStudy 1EC&SS2 333 ublished in the New England Journal of Medicine inSetember ());

3t is a double"blinded lacebo"controlled study with ;(. atients randomizedto 3A rt"<& or lacebo




<atients who received intravenous rt"<& administeredbetween ' and 8/ hours after the onset of symtomshad statistically si%nificant imroved clinicaloutcomes comared with lacebo 1/(8: vs 8/(:<))82

+he incidence of symtomatic 3C! was hi%her with rt"<& than lacebo 1(8: vs )(: <)));2, butmortality did not si%nificantly differ between the two%rous




3n ay ())7, the &merican !eart &ssociation> &merican Stroke &ssociationreleased a Science &dvisory recommendin% the e5ansion of the time windowfor treatment of acute ischemic stroke with rt"<& from ' hours to 8/ hoursafter onset of symtoms




!owever, the D& has declined to e5tend the aroved time window for 3A"t<&administration beyond ' hours



&cute mana%ement@ endovascularthrombolysis

Endovascular theray for acute ischemic strokeincludes intra"arterial fibrinolysis, mechanical clotretrieval or a combination of the two

+here has been a - fold increase in endovasculartreatment from ())8 to ())7 1).: vs )-: <F))).2

ortality decreased 1OR)6 <)))62, butmoderate to severe disability increased from ());"())7 1OR.8 <))))(2




8 mechanical devices with D& clearance@ erci RetrievalSystem 1())82, the <enumbra System 1())62, the Solitairelow Restoration Device 1().(2, and the +revo Retriever1().(2

Devices are cleared as mechanical means forrecanalization of acutely occluded arteries based onstudies without noninterventional control %rous















&cute ana%ement@ endovascularthrombolysis

' endovascular thrombectomy trials were hi%hli%hted at the ().'3nternational Stroke Conference

3S 333

R RESC4E

S#+!ES3S E5ansion




&ll ' trials failed to show a statistically si%nificant difference between theendovascular theray %rou and the best medical mana%ement %rou 1whichcould include 3A"t<&2 as measured by an mRS of ( or less



MR CLEAN: A Randomized Trial of Intra-arterial Treatment

for Acute Ischemic Stroke

Multicenter R andomized Clinical trial of Endovascular treatment for Acuteischemic stroke in the Netherlands

<ublished Hanuary ., ()./

/)) atients with lar%e vessel occlusion1=AO2 confirmed by C+& wererandomized to intra"arterial treatment 1n(''2 or medical mana%ement1n(-62 within - hours of symtom onset

'(-: of atients who received endovascular treatment achieved a %oodfunctional outcome 1mRS )"(2 comared to .7.: of atients who receivedmedical mana%ement

Berkhemer O& et al # En%l H ed ()./'6(@.."()



MR CLEAN: A Randomized Trial of Intra-arterial

Treatment for Acute Ischemic Stroke

Berkhemer O& et al # En%l H ed ()./'6(@.."()




' endovascular thrombectomy trials were hi%hli%hted at the ebruary ()./3nternational Stroke Conference in #ashville, +#

ESC&<E

EI+E#D"3&

S03+ <R3E




&ll ' trials showed a statistically si%nificant difference between theendovascular theray %rou and the best medical mana%ement %rou 1whichcould include 3A"t<&2 as measured by an mRS of ( or less



ESC&<E@ Randomized &ssessment of RaidEndovascular +reatment 3schemic Stroke

<ublished ebruary .., ()./ +rial was stoed early because of efficacy

'.- atients with ro5imal lar%e vessel occlusion 1=AO2 and %ood collateralcirculation confirmed by C+& were randomized to endovascular intervention1n.-/2 or medical mana%ement 1n./)2 within .( hours of symtoms onset

Rates of functional indeendence 1mRS )"(2 at 7) days was statistically

si%nificant for the endovascular intervention %rou comared to the control%rou 1/'): vs (7': F ))).2

Endovascular intervention was associated with reduced mortality 1.)8: vs.7): ))82

Goyal et al # En%l H ed ()./ DO3@ .).)/->#EHoa.8.87)/



ESC&<E@ Randomized &ssessment of RaidEndovascular +reatment 3schemic Stroke

Goyal et al # En%l H ed ()./ DO3@ .).)/->#EHoa.8.87)/

EI+E#D"3&@ Endovascular +heray for 3schemic



EI+E#D"3&@ Endovascular +heray for 3schemicStroke with <erfusion"3ma%in% Selection

<ublished ebruary .., ()./ +rial was stoed early due to efficacy

6) atients with internal carotid or middle cerebral artery occlusion,salva%eable brain tissue, and ischemic core F 6) ml confirmed by C+< wererandomized to endovascular thrombectomy with the Solitaire R stentretriever 1m'/2 or altelase alone 1n'/2 within 8/ hours of symtom onset

+he endovascular reerfusion %rou achieved %reater reerfusion at (8 hours1median, .)): vs '6: ,))).2 and increased early neurolo%ic imrovementat ' days 1;): vs '6:, )))(2 as measured by the #3!SS

#o si%nificant difference in mortality or symtomatic 3C!

Cambell BC et al # En%l H ed ()./ DO3@ .).)/->#EHoa.8.867(



EI+E#D"3&@ Endovascular +heray for 3schemicStroke with <erfusion"3ma%in% Selection

Cambell BC et al # En%l H ed ()./ DO3@ .).)/->#EHoa.8.867(



S03+ <R3E

Results resented at 3SC on ebruary .., ()./ +rial was stoed early due to efficacy

.7- atients with lar%e vessel occlusion 1=AO2 confirmed by C+& or R& wererandomized to endovascular treatment with the Solitaire R stent retriever1n7;2 or altelase alone 1n7;2 within - hours of symtom onset

+he OR for mRS shift at 7) days in the endovascular treatment %rou

comared to the altelase alone %rou was statistically si%nificant1))))(2, and %ood functional outcome 1mRS )"(2 was achieved in -)(: ofthe atients in the endovascular treatment %rou comared to '//: of theatients in the control %rou 1))));2

Saver H 3nternational Stroke Conference ()./ 3nvited <resentation <resented ebruary .., ()./



S03+ <R3E@ Secondary Endoints

Endpoints EndoascularTreatment

Control P !alue

mRS score of ) " ( at7) d 1:2

-)( '// )));

ortality 1:2 7( .(8 /)

ean imrovementin #3!SS score at (6h 1oints2

;/ '7 F))).

Saver H 3nternational Stroke Conference ()./ 3nvited <resentation <resented ebruary .., ()./



3mact on acute stroke treatment

&ll 8 trials showed statistically si%nificant evidence of endovascular treatmentin select acute ischemic stroke atients

Selection of atients should be confirmed by vascular ima%in%

3A rt"<& should always be the first line treatment for eli%ible acute ischemicstroke atients

On avera%e aro5imately /: of stroke atients receive acute stroke

treatment 0e need to continue to imrove community and hysician awareness



obile Stroke 4nits

obile Stroke 4nits debuted in Cleveland and !ouston durin% the ast year 4nits resemble a tyical ambulance, but are e?uied with a ortal C+

scanner, lab testin% caabilities and the ability to administer 3A"t<&

obile Stroke 4nits cost about 9. million and are staffed with a critical carenurse, a aramedic and C+ technolo%y e5ert

<hysicians are able to remotely evaluate a atient with two"way video

conferencin%



obile Stroke 4nits

3n Cleveland, the stroke unit oerates from ; am to ; m daily Researchers found that on avera%e atients received a C+ scan () minutes

faster than throu%h the EC

+here was also a si%nificant reduction in avera%e treatment time for themobile stroke unit 1-8 minutes2 comared to the emer%ency room 1.)8minutes2

!ussain S 3nternational Stroke Conference ()./

h i d d d i if bil k



ore research is needed to determine if obile strokeunits lead to overall better stroke outcomes and ifthey are cost effective in different locations

C l



Conclusion

Every minute .7 million neurons die durin% a stroke Hust because we have 8/ hours to administer 3A rt"<&, does not mean that we

should wait 8/ hours to %ive 3A rt"<&

Endovascular reerfusion theray is beneficial for aroriately selectedstroke atients

+ime is brainJ

K i L



KuestionsL

+hank youJ

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Grysiewicz ECI