Report – Coming together for Stroke Management

Day 1. Monday, 3 October

The second edition of the increasingly international Stroke Live Course (SLICE) began today in the beautiful city of Nice, France. As announced in the opening ceremony, the aim of SLICE is to be an international multidisciplinary brainstorming session centering on the acute phase management of ischemic stroke patients. To do this, during SLICE, we cover the neurological, anesthesiological and neuroradiological aspects of disease management. Of the attendees this year, 28% are interventional neuroradiologists with 72% representing others specialties, the majority being neurologists.

A morning based on IV thrombolytics

In this first topic, Dr Arquizan tried to offer an answer to the eternal question: IV or not IV?

There are four reasons to continue giving IVTPA:

  1. IVT is highly effective in all subgroups of ischemic stroke;
  2. IVT was administered in almost all patients in recent intraarterial treatments (IAT) trials and remains the standard of care;
  3. There is some risk of “bypassing” the primary stroke center;
  4. New strategies/New thrombolytics drugs are currently being tested (Tenecteplase) which promise to be more effective and safer.

In some situations, mechanical thrombectomy alone may be effective and in the future we need to test this protocol in randomized trials.

Whatever treatment is given, one rule remains constant: “the fastest is the best”!

The day’s second topic was presented by Dr Mordasini, who began by summarizing the well-known limitations of IVTPa:

  1. rtPA equals poor recanalization rates in large vessel occlusion;
  2. rtPA has a narrow time window with decreasing efficacy;
  3. rtPA has multiple absolute/relative contraindications;
  4. rtPA has (relative) contraindications for IA lytics/antiplatelets/heparin;
  5. rtPA increases the risk of hemorrhage;
  6. rtPA may produce thrombus dislocation;
  7. rtPA has a major impact on healthcare costs ($3,000.00);
  8. rtPA may cause life-threatening complications;
  9. rtPA may delay EVT in some patients.

Dr Mordasini then highlighted two studies showing similar results regarding mechanical thrombectomy (MT) as compared to IVT:

  • Equal recanalization rates and similar (or even better) outcome can be achieved by IVT and MT;
  • MT can decrease hemorrhage rates; and
  • MT can avoid thrombus migration.

He concluded that IVT will remain the standard of care until a trial is done comparing MT directly to bridging thrombolysis.

 

Challenging clinical cases

We observed four different clinical cases from the USA (Denver, CO and Atlanta, GA) and Europe (Montpellier, France and Stockholm, Sweden). All these cases provided a great opportunity for debate, which occurred on topics such as:

  • The importance of imaging and the need or not of advanced imaging.
  • Patient selection: Should we treat patients with low NIHS score?
  • Technical approaches to mechanical thrombectomy
    • Here we discussed the fact that the majority of these are routinely accomplished using a balloon guiding catheter and an intermediate catheter. In two of the cases presented in Nice, the operators chose to go for aspiration first and achieved a TICI 2b/3 result after a maximum of two passes.

 

The first day’s symposium

Dr. Hannes Normeyer from Germany presented the first experience with the new Solitaire™ Platinum device, the next generation of stent retrievers from Medtronic. This innovative device promises enhanced visibility with additional marker bands throughout the working length of the stent. In all five cases presented, recanalization TICI 2b/3 was achieved. The conclusions from this early experience are that:

  • Solitaire™ Platinum has a lower delivery force than Solitaire 2, even when used in 0.21 microcatheters
  • It offers excellent visibility, with detection of stenosis as well as lost or immobile thrombi
  • It’s length is appropriate, covering long thrombi or tandem occlusions

 

A silicon model workshop

A video case of thrombectomy performed using the Solitaire 2 associated with the Lazarus cover stent was discussed. For now, although clinical experience is convincing, physicians believe there is some aspects of this prototype that need to be improved (covering the origin of the A1, enhancing its relation to the stent retriever).

 

Patient workflow

Everybody agreed on the critical importance of the patient workflow. There was also a general convergence on how to improve workflow in order to reduce the time between stroke onset and recanalisation.

This period of time can be stratified into several steps:

  • Symptoms Identification – How to educate EMS services to recognize stroke symptoms (RACE)?
  • Bypass strategy – In those cases where there is a suspicion of large vessel occlusions, should we systematically bypass the primary stroke center and go directly to the comprehensive stroke center?
  • Door to groin puncture – Is the goal of performing this in less than 30 minutes achievable? How can we accomplish this?
  • Repeat imaging – Should we perform another series of imaging if the patient is clinically stable between the primary stroke center (PSC) and the CSC?

After this rich first day all the SLICE online team and SLICE organization here in Nice wish you the best…and we look forward to a great second day at the Stroke Live Course!

 

Gregory GASCOU, MD

Gregory GASCOU