endovascular therapy: modena experience

Endovascular therapy:

Modena experience

Dott.S. Vallone

NEURORADIOLOGIA

AUSL MODENA

Stentriever

Responsabili del progetto

Salvatore Mangiafico, Danilo Toni

Comitato scientifico

Alfonso Ciccone, Domenico Inzitari, Patrizia Nencini, Andrea Zini

Francesco Causin, Roberto Gasparotti, Stefano Vallone

Coordinamento tecnico

Giovanni Pracucci, Valentina Saia

Organizzazione del Registro

30 active centers

Mappa SU I e II livello per Area Vasta

SU I Livello

SU II Livello = 500 casi/anno

TC

Hyperdensity ACM

dx

Hypodensity

Angio TC

Occlusion ICA dx - Occlusion ACM dx

TC PERFUSION

MTT

CBV

MTT Volume

MISMATCH. MTT-CBV

Angiografia

Subocclusione ICA dx dal tratto iniziale Flusso invertito sull’ACA dx visualizzata

attraverso la comunicante anteriore dopo

Iniezione dell’ICA sx

PTA con stent in ICA dx

Posizionamento di stent in ICA dx Ricanalizzazione ICA dx .

Non visualizzazione ACA e ACM dx

Superamento del trombo con

stent TrevoPro retriever

TROMBECTOMIA

Occlusione T carotidea dx

Ricanalizzazione del circolo intracranico carotideo dx

TC di controllo

ischemia caudato e capsula interna dx

TC a 24 ore TC post angiografia Volume TC perfusione in entrata

Ischemia del nucleo caudato e del braccio anteriore della capsula interna dx

NO MISMATCH

CORE ALLA TC PERFUSION

(ALGORITMO VOLUME)

ZONA DI IPOPERFUSIONE ALLA TC PERFUSION

(ALGORITMO FLUSSO)

ZONA DI IPOPERFUSIONE ALLA TC PERFUSION (ALGORITMO TEMPO DI TRANSITO MEDIO)

INFARCIMENTO DOPO DISOSTRUZIONE

TC perfusion (volume sanguigno) TC dopo fibrinolisi intra-arteriosa

2 ore e 40 minuti dall’ictus

NO TRATTAMENTO IA : craniotomia

TAC after 6 month

Emiplegia dx e afasia da 2 ore e 50 minuti

BASICS trial

RESCUE THERAPY

Modena - Karolinska Stoccolma

NIHSS >15

Popolazione 1.224.155 abitanti

535.869 ab 688.286 ab

Hub ASMN 491

AUSL RE 353

Tot. 844 AUSL 1.119

AOP 52

Tot. 1.171

MR CLEAN -­‐ MULTICENTER RANDOMIZED CLINICAL TRIAL OF ENDOVASCULAR

TREATMENT FOR ACUTE ISCHEMIC STROKE IN THE NETHERLANDS

DESIGN

MR CLEAN is a pragmatic phase III multicenter randomized clinical trial with blinded

outcome assessment. The intervention contrast is Intra-arterial treatment vs. no intra-

arterial treatment. (PROBE)

POPULATION:

Patient with ischemic stroke, MRI or CT ruling out intracerebral hemorrhage, NISHH ≥2, a

relevant intracranial occlusion, demonstrated by neuro-imaging and the possibility to start

neurovascular treatment within 6 hours after Onset.

INTERVENTION

The exact choice of endovascular treatment modality for each patient is left to the

discretion of the local investigator and treating physicians

OUTCOMES

The primary outcome is the score on the modified Rankin scale (mRS) 90 days after inclusion

in the study. Secondary outcomes are the NIHSS score at 24 hours, vessel patency at 24

hours and infarct size at day 5--‐7 and the occurrence of major bleeding

Baseline was

500 patients were included randomized between both groups.k

Baselined characteristics really similar for both groups

NIHSS score ~17

IV tPA ~ 90% of the patients

Occlusion site: ~ 30% ICA-T, > 60% M1; < 10%M2

Interventions:

Time from Onset to groin puncture 260 min (mean)

97% patient were treated with Stentrievers. (COMMENT: Majority Trevo, really high MS in NL,

Minimal use of other techniques like aspiration, Adapt…)

Adverse effects

Both groups have similar adverse effect.

Stroke in a new territory was 5.6% for the endovascular group

Results.

Recanalization TICI 2b/3 59%

mRS score: Odds ratio 1.69 favorable outcome for Mechanical Thrombectomy. mRS 0-2 33%

vs19%

It shows that a patient treated with Mechanical

Thrombectomy has 1.69 more chance to have a

positive outcome than without

Conclusion:

The Intra-Arterial treatment in patient with acute

ischemic stroke caused by intracranial anterior

circulation occlusion IS EFFECTIVE and SAFE

within 6 hours from Stroke Onset.

Endovascular therapy:

Modena experience

Dott.S. Vallone

NEURORADIOLOGIA

AUSL MODENA