Ram narayan Chabra

BALLOON ASSISTED COILING IN RUPTURED CEREBRAL ANEURYSMSVipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon

Mechanical thrombectomy with stent retriever-How do we do it

Intra- arterial methods

Randomised trials General criterionRandomised (Intervention Vs Standard medical therapy)Documented site of occlusion.Time based: 6 hrs (initiation of IA therapy)Small CorePredominantly stent retrievers.

MR CLEAN TrialNetherlands, 2015ESCAPE TrialCanadian, 2015EXTEND-IA TrialAustralian, 2015SWIFT PRIME TrialUSA, 2015REVASCAT TrialSpanish, 2015

TICI 2B/3 59% - 88% - (previous trials 25%, 41%) Recanalization TICI 2B/3

Absolute Benefit (good outcome) : 13.5% to 31.4%(Statistically significant)mRS (90 d)

no significant differencesICH

Device complication

Absolute mortality benefit : 8.6%(Statistically significant in ESCAPE)Mortality

AHA/ ASA guideline 2015:

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):

prestroke mRS score 0 to 1acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset causative occlusion of the internal carotid artery or proximal MCA (M1) age 18 yearsNIHSS score of 6ASPECTS of 6treatment can be initiated (groin puncture) within 6 hours of symptom onset

AHA/ ASA guideline:

Carefully selected patients with anterior circulation occlusion who have contraindications to intravenous r-tPA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable (Class IIa; Level of Evidence C).

Carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries (Class IIb; Level of Evidence C)

AHA/ ASA guideline:

Stent retrieval may be reasonable for patients with acute is initiated (groin puncture) within 6 hours of ischemic stroke in whom treatment can be of symptom onset and who have prestroke mRS score of >1, ASPECTS >1, ASPECTS