How to best take charge of your Stroke patient– from the first signs and symptoms to mechanical thrombectomy and beyond!
The first lecture of this year’s SLICE by Dr. C. Arquizan looked at the experience of the Occitanie Region in France and what happens when patients bypass primary care centers. Should this should be considered mandatory in 2018.
Dr. Arquizan discussed the importance as well as the difficulties in the case of a suspected stroke in taking a pre-hospital decision concerning patient transportation (PSC vs. CSC). She presented a unique protocol composed of major and minor criteria being used in the Occitanie whose purpose is to make primary evaluation easier, faster and more accurate – thus assisting overall in the decision-making process. She shared with the audience her personal experience using this method.
This was followed by a lecture/debate between Drs. J.M. Olivot and R.G. Nogueira on “Less imaging = more brain or more futile treatment?” Dr. J.M. Olivot and Dr. R.G. Nogueira each presented their opposing approaches to imaging in an acute setting (0-6 hours from onset) which led into an exciting debate took place.
Dr. Olivot claimed that performing an extensive imaging profile is mandatory and an integral part of patient selection. “Despite taking time”, he explained, “excellent, combined imaging techniques can decrease the number of futile and even harmful treatments”.
On the contrary, Dr. Nogueira stated that extensive performance of tests during the acute phase might be a limiting factor that could delay and even prevent fast and necessary treatment.
Both presenters discussed the different types of imaging protocols along with their advantages and disadvantages, presenting clinical cases and, in general, based their opinions on relevant recent trials and papers.
Stroke recorded cases
The “Stroke recorded cases”, with an open discussion between the expert panel, presenters and all the SLICE participants, followed.
Case 1, by Dr. J. Gralla, was that of a young patient with a T-occlusion who was transferred initially to a PSC where IV lytics were given and then to a Comprehensive Stroke Center (CSC). At the CSC a Mechanical Thrombectomy (MT) was performed during which contralateral side involvement was demonstrated in order to illustrate the collateral pattern. This approach was not acceptable to several audience members who considered the risk of complications to significant. After a successful single stent retriever, a second thrombus was shown in a different region. Further discussion about the need of MT while thrombolysis is on board took place.
Dr. F. Mont’alverne presented the second case, a tandem occlusion in which it was impossible to pass the cervical lesion, challenging the operator to find a different access to the occluded M1. After a relatively large ipsilateral PCOM was discovered, it was decided to try to perform MT through it. After a first unsuccessful attempt using a stent retriever, Dr. F. Mont’alverne’s team made another attempt using a stent retriever in combination with aspiration and achieved full recanalization.
Case 3, presented by Dr. Dolveck, was an example of an emergency service where the primary triage is performed by telephone with a secretary using the FAST score. Upon arrival, the EMS team performs further evaluations using the RACE score and then discusses with a medical doctor who decides whether to transfer the patient to a PSC or directly to a CSC. This case raised another point due to the fact that the patient experienced a contralateral LVO one day after the primary attack. An interesting debate ensued concerning IV lytics administration in this case which raised such questions as hemorrhagic risk, MT and the validity of current guidelines.
Case 4, concerned a basilar artery occlusion and the use of a stent retriever. It was presented by Dr. R. Chapot. The necessity of a CT angiogram, the presence of the hyper-density of the basilar artery, the positioning of a balloon-guided catheter in the posterior circulation and the use of aspiration as an alternative to stent retrieving were all discussed.
Recorded thrombus lab: Thrombectomy tips and tricks
Using a silicon model, Dr. G. Gascou presented an MT in cases of calcified thrombus. Dealing with a unique and usually angiographically invisible thrombus, he described – and demonstrated – the difficulties in retrieving or aspirating a hard thrombus. Keeping in mind the potential damage of repeated passes, he suggested rescue stenting pushing the calcified thrombus toward the vessel wall and maintaining a patent vessel. The audience shared their experience regarding this interesting topic and the efficiency of lytics in this situation was questioned. With 10% chance of revascularization and 60% mortality rate in those cases when a thrombus is left behind, rescue stenting seems to be a promising solution.
As stroke treatment is a major economic question, M. Cuche presented a detailed presentation concerning stroke economics itself.
Looking at current studies which show that repeat passes have a negative influence on prognosis, first pass success is clearly the goal. In relation to this, Dr. Ribo introduced several new devices aimed at allowing “one pass” thrombus retrieval.
The day was completed with a series of interesting presentations
A live demonstration was given of patient immobilization by J. Ghekiere and E. Tronel Peyroz.
Blood pressure during thrombectomy and other updates on neuroanasthesia
Dr. J. Bösel discussed the influence of blood pressure levels on cerebral blood flow and prognosis before, during and after MT.
After presenting supporting trials, he summarized the data that showed that high blood levels before MT are consistently associated with worse outcome and that low blood pressure levels during MT are associated with bad ones.
Today we have no specific protocols for the post-procedural period and usually treatment is individualized based on the general condition of the patient, reperfusion and parenchymal damage.
During his second topic – GA vs. CS – Dr. Bösel presented the advantages and disadvantages of each technique and presented several studies which dealt with this issue.
RACECAT trial: design and first results
Dr. Ribo presented the intermediate results of the trial.
Diligently collecting patients as well as data Dr. Ribo aroused our curiosity regarding the results of the study.
We will have to continue waiting…with patience.
Drip and Drive – ship the interventionalist and not the patient for MT!
Both currently modes of transportation in use today (drip and ship or mothership) can lead to significant delays in treatment. A new concept, “Drip and Drive”, proposed direct transportation of an operator to the PSC where MT can be performed.
Dr. C Brekenfeld offered us new data regarding these different approaches to transportation – and effective patient care.
Re-thinking time to intervention: what can we learn from the business world?
Dealing with the high number of patients, Dr. F. Hui presented one of the major challenges facing us today – how to provide every patient with the treatment they deserve…and need. Confronted with large demographic areas, along with transportation and financial limitations, the need for creative and brave steps are required and need to be taken.
My place as an interventional radiologist in the stroke pathway
Dr. H. Van Overhagen discussed this common daily question and showed how good training and multidisciplinary decisions were important and should be encouraged.
At the end of this interesting session the expert panel debated with the speakers as well as the audience – and did not always reach a consensus, but together we built on the ideas and exchange of experience of each of us.
After such a long and full day what better thing to do?
We all went for a run on the beautiful boardwalk that is one of the symbols of Nice, France!
Shani AVNERY KALMANOVICH
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital