急性缺血性脑卒中血管成形术(英文).ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Emergent Revascularization For Acute Ischemic Stroke,Rishi Gupta,MD,Staff,Cerebrovascular Center,The Cleveland Clinic Foundation,Introduction,-There are 700,000 ischemic strokes/year in the U.S.,-70%of patients with cerebral occlusions,-Since 1995,IV t-PA utilized within 0-3 hour time window,1,-Rates of delivery 3-19%at specialized centers vs.1-2%,in the community,-Other therapeutic options needed to benefit larger number of,patients,1,NINDS t-PA study group,NEJM 1995,2,Hacke et al.Lancet 2004,Intro(Contd),Potential ways to increase patients being treated:,1)Utilization of perfusion mismatch to select patients,for thrombolytic therapy,2)Endovascular techniques to achieve recanalization:,-Mechanical methods without thrombolysis for later strokes,Large Vessel Occlusion,-Toni et al.showed 25%of patients with acute stroke deteriorate,within 96 hours=poor long term prognosis,5,-Further evaluation showed improvement was linked to arterial,patency or presence of collaterals,-Interestingly,15-20%of patients have a delay in deterioration linked,to vessel occlusion+poor collaterals,6,5,Toni,et al Stroke 1997,6,Toni et al.Arch Neurol 1995,-The use of perfusion imaging has been studied to select patients,beyond 3 hours for thrombolysis,Two techniques utilized to assess mismatch,MRI perfusion/diffusion imaging,-difficult to obtain urgently in many centers,CT perfusion imaging,-can be done in the ER quickly,Semi Quantitative CBF Estimates,Thijs,et al.,1,looked at 12 patients with acute stroke 20%PWI/DWI mismatch,MRI obtained at 4 to 7 days after stroke to compare final infarct volume,to initial DWI lesion,1,Thijs VN et al.Neurology 2001,Example of PWI/DWI mismatch and final infarct,Cerebral Blood Flow changes in Acute Ischemic Stroke,Tissue outcome following arterial occlusion is determined by cerebral blood flow thresholds below which neuronal integrity and function is differentially affected,1,1,Baron JC,Cerebrovasc Dis 2001,CBF thresholds in human cerebral ischemia,ISCHEMIC PENUMBRA,Tissue that is functionally impaired but structurally intact,CBF range 12-20 mL/100g/min,Salvaging this tissue by restoring its flow to non-ischemic levels is the aim of reperfusion therapy,Penumbra converts to ischemic core with hyperglycemia,acidosis,reduced local perfusion pressure,1,Baron et.al,Cerebrovasc,Dis,2001,2,Heiss,et al.2001,Cerebral Blood Flow changes in Acute Ischemic Stroke,23 patient with MCA occlusion 6 hour symptom onset and imaged,with Xenon CT prior to IA lysis,1,5 patients developed parenchymal hematoma post IA-,lysis,with t-PA,Univariate,modeling found patients with hyperglycemia,higher%core infarct(33%)and low CBF at higher risk of ICH,Patients with a mean hemispheric CBF 13 cc/100 g/min were at,significantly higher risk of ICH,1,Gupta R,et al Stroke 2006,Xenon CT(Quantitative CBF),CT Perfusion,Retrospective review of 57 patients treated with Intra-arterial,t-PA for MCA occlusion,Mean NIHSS=16,CT Perfusion performed prior to infusion of IA t-PA,Patients with lower pre-treatment Cerebral blood volume found to be at increased risk of intracranial hemorrhage,-16 of 19 patient with hemorrhage initial CBV 2.0 mL/100 g,CBF,Ipsilateral Cerebral Blood Volume(mL/100 g),5.000,4.500,4.000,3.500,3.000,2.500,2.000,1.500,1.000,0.500,0.000,50.00,45.00,40.00,35.00,30.00,25.00,20.00,15.00,10.00,5.00,0.00,CBF,mL/100g/min,Scatterplot of patients comparing CBF to CBV,In patients treated with IA Thrombolysis,LIMITATIONS OF INTRAVENOUS TPA,Recanalization rate poor for larger arteries such as ICA or proximal MCA,Outcomes for MCA occlusions poor,No information regarding site or presence of arterial occlusion,Effectiveness beyond 3 hours not established,i.v t-PA recanalization at one hour(angiographic data),Del Zoppo et al.,Ann Neurol 1993,Intra-arterial Options,Chemical thrombolysis,Balloon Angioplasty,Clot Retrieval,Clot Maceration,Stents,-Multi-modal(combination chemical+mechanical),Intra-arterial(Contd),Advantages,Maximum delivery of lytic agent,Endpoint of clot lysis,Not given if spontaneous clot lysis,Disadvantages,Time necessary to place catheter,Requires interventionalist,Emergent availability of angiography,PROACT II,Randomized multicenter controlled trial,9 mg IA r-proUK+IV heparin v.IV heparin alone,Randomized 2:1 to treatment v.control,180 pts with M1 or M2 occlusion by angio,Treatment started within 6 hours of stroke onset,IA r-proUK infused over 2 hours then repeat angio,Primary endpoint-mRS 2 at 90 days,PROACT II:MCA RECANALIZATION,4%,19%,2%,63%,66%,18%,TIMI 2+3,TIMI 3,(P=.001),(P=.003),ANGIOGRAM,IMS TRIAL Design,Eligible,patients,Start IV,t-PA entry into study,(0.6 mg/kg,15%bolus,30 min inf.,60 mg max.),Angiography,Thrombus,No,clot stop,Clot IA Therapy:,2 mg-distal,2 mg-intraclot,9 mg/hr x 2 hrs,22 mg max.),Favorable Outcome,at 3 months(%)*,IMS,Study,(n=80),NINDS,Placebo,(n=211),Odds Ratio(95%CI),Rankin 0-1,30%,18%,2.29,(1.2,4.4),Rankin 0-2,43%,28%,2.04,(1.2,3.6),NIHSS 1,25%,15%,2.24,(1.1,4.5),*,Adjusted for baseline NIHSS and time-to-treatment,Issues with IA Chemical Lysis,Time consuming to dissolve clot,May be ineffective with long segments of clot,Platelet rich/Plasminogen poor clots resistant to IA thrombolysis,Mechanical thrombolysis,MERCI trial,Study to determine the safety and potential efficacy of the MERCI,clot retriever device in patients with cerebral artery occlusion 8 hours(MCA,ICA or basilar),Clinical signs consistent with the diagnosis of ischemic stroke,Must meet either population,0-3 hours,contraindicated for IV tPA,3-8 hours,NIHSSS 8,Angiogram shows a thrombotic occlusion in the internal carotid artery,M1 and/or M2 segment of the middle cerebral artery,basilar or vertebral artery,A total of 151 patients enrolled and 141 treated with MERCI device,The overall recanalization rate with the device was 48%this was significantly higher then control arm of PROACT II,Clinically significant procedural complications were 7.1%,Symptomatic ICH occurred in 7.8%of patients,Recanalization rate was lower then PROACT II(66%vs.48%),authors argue because PROACT was MCA only lesions,while MERCI any arterial occlusion,The interventionalists graded rates of recanalization in MERCI trial,in PROACT a core lab graded recanalization,Nakano et al.,Stroke 2003,MCA angioplasty,Multimodal Endovascular Therapy,Retrospective review of 168 patients over,6 years treated for acute cerebral,arterial occlusions,1,Purpose was to determine which modality,lead to the highest recanalization rates,1,Gupta R et al.Stroke 2005,TIMI 2-3,N(%),TIMI 3,N(%),Sx Hemorrhage,Asx Hemorrhage,One Modality(N=40),20(50%),10(25%),5(13%),8(20%),Two Modalities(N=65),39(60%),18(28%),9(14%),14(22%),Three+modalities(N=63),45(71%),*,25(40%),*,10(15%),14(22%),*,p0.045,*p0.012,Independent predictors of TIMI 2 or 3 flow after,endovascular intervention in Acute stroke.,Variable,Odds Ratio,95%CI,p-value,ICA Terminus,0.3,0.16-0.73,0.006,GP IIb/IIIa +IA thrombolytics,2.9,1.04-6.7,0.048,Extra-cranial Stenting,4.2,1.4-9.8,0.01,Intra-cranial Stenting,4.8,1.8-10.0,0.01,Tx Modality,TIMI 2-3 Flow,(ICA/M1 MCA),Symptomatic Hemorrhage Rate,IV t-PA,1,25%,5-7%,IV t-PA+TCD,2,46%,6%,IA pro-UK,3,66%,10%,MERCI clot retrieval,4,55%,7%,GP IIb/IIIa+IA Lytics,85%,5%,Multimodal Therapy,70%,11%,Angioplasty,7,60-90%,7%,Primary Stenting,8,90%,5%,Summary of Tx Modality and Recanalization Rate,Case Example,-45 year old man arrived at our ER 12 hours from symptom,onset with left hemiparesis+right gaze preference,(NIHSS 11),A CT head with large perfusion deficit+,CTA with RICA occlusion,-MRI brain at 15 hours with infarct in the right insular cortex,CBF,MTT,RICA occlusion,At 24 hours,patient has,hemiplegia,(NIHSS 16),A repeat MRI performed showing extension of infarct,into right posterior temporal and frontal areas,A Xenon CT performed at 28 hours to determine degree,of tissue at risk,CBF measurements in right hemisphere at,18 cc/100 g/min,suggesting more tissue at risk,Patient taken to angiography,RICA occluded,R MCA patent via,ACOMM,Collaterals via PCOMM,Microcatheter distal,to occlusion,Post stent/plasty shows patent,RICA,-Xenon CT post stent reveals normal and symmetric CBFs,-MRI post stent shows no further increase in infarct burden,Patient improved to a NIHSS of 10 the next day,At 30 day f/u has a NIHSS of 6 with a mRS of 2,Conclusions,Endovascular therapies may have benefit in select patients,-Utilization of perfusion studies may improve patient selection,-A better understanding of the treatment modality utilized may,reduce complication rates,