A morning lecture
We began the last day of SLICE 2018 with Dr M.J. Alexander who presented the final results of the WEAVE trial. This trial aimed at evaluating the rate of stroke and death within 72-hours post-operative in patients treated with the Wingspan stent system for intracranial stenosis. We all hope this will finally shed light on a controversial issue.
Cases…and more cases
The “Call of Cases” session followed, with the first case of a young patient with cervical dissection and a stroke introduced by Dr. F. Asteggiano. Upon passing the cervical lesion an intracranial leak was seen by contrast and they were forced to stop. In trying to understand why one patient bleeds and another does not, the audience and the expert panel shared their personal experience and recommendations.
The second case, presented by Dr A. Carneiro, was a patient with minor stroke symptoms and intracranial stenosis. During the procedure the team decided to put in a stent. After the procedure, a CT scan demonstrated intracerebral hemorrhage and a craniectomy was then performed. The discussion that followed concerned the risks, in the setting of an acute stroke, of the use of abciximab during a procedure and dual-antiplatelet therapy afterwards, especially while IV lithics are on board.
Dr. L. Albuquerque presented the next case of an ICA perforation which occurred while attempting to pass a cervical occlusion. In trying to understand the cause of this rare situation the audience and expert panel had a range of ideas regarding the pathophysiology of the cervical lesion itself and the mechanical technique used.
We then turned to the pre-recorded videos of cases specially prepared for SLICE, beginning with a presentation by Prof V. Costalat of a patient with LVO and a low NIHSS score. Taking into account the imaging results, a discussion ensued concerning the risks and the benefits and the necessity of MT in these cases.
The next special case was a delayed MT performed 24 hours after symptoms onset presented by Dr R. Chapot. Dealing with a difficult access, a direct carotid puncture was performed. Dr. Chapot shared his personal experience in using an Angio-Seal as the hemostatic device for direct carotid puncture.
Dr. Chapot presented the final case of the morning, a case of an M1 occlusion with a high probability of a chronic intracranial occlusion due to the low NIHSS scored as compared to the occlusion site, the good pial collateralization and the absence of a dense MCA sign on the CT. A discussion followed concerning IV lithic use in this situation and the technical approaches involved.
A last afternoon together
Dr. W. Van Zwan gave us an detailed view of the state of Stroke trials…today, and in the future looking at what we should expect in the coming months in his lecture entitled, “RCTs to come in 2018”. Before giving a short summary of each of trial, he discussed two studies which prove the cost effectiveness of MT in the treatment of acute ischemic stroke. Turning to the RCTs, he reviewed:
- MR CLEAN IV – to determine whether direct MT is more effective than MT preceded by IV alteplase.
- MR CLEAN MED – looking at the administration of antithrombotic drugs (aspirin or heparin or both) during MT.
- MR CLEAN LATE – looking at endovascular treatment of acute stroke for late arrivals (6-24 hours).
- MR ASAP – examining acute stroke treatment in the ambulance with nitroglycerin patch.
- SWIFT-DIRECT – in the case of acute anterior circulation stroke, this trial is designed to compare the eventual use of a Solitaire device with the intention for thrombectomy plus IV t-PA vs. direct thrombectomy using a Solitaire stent retriever.
- TENSION trial – aiming is to evaluate the efficacy and safety of MT in stroke with extended lesions as well as an extended time window.
- IN EXTREMIS: looking at patients who had been “automatically” ruled out for MT and who might still benefit from this treatment as well.
- MOSTE – an evaluation of MT in LVO with minor symptoms (NIHSS<6) in patients last seen well < 24 hours.
- LASTE – an evaluation of acute MT in large stroke (ASPECT 0-5) with LVO.
- BASICS – whose aim is to evaluate the efficacy and safety of IAT in addition to BMT in patients with basilar artery occlusion.
- BASILAR ARTERY OCCLUSION CHINESE ENDOVASCULAR TRIAL – looking at whether mechanical embolectomy with the Solitaire device is superior to medical management alone in achieving meaningful outcomes (better than death or equivalent).
After this lecture, Dr. R. Nogueira presented the AURORA trial, analyzing pooled data from randomized studies such as i.e. DAWN, DEFUSE-3, POSITIVE, ESCAPE and REVASCAT and looking at outcomes in patients undergoing thrombectomy more than 6 hours after last known period where they were seen or reported as feeling well.
A sponsored symposium took place where D. Fiorella presented new technology along with advanced techniques using the penumbra system.
Once again, in the recorded thrombus lab, using a silicon model Dr. G. Gascou presented the technical approach to atheromatic tandem occlusions. After demonstrating carotid occlusion crossing, intracranial stent retrieving using a triaxial system combined with proximal protection (balloon and aspiration), Dr Gascou concluded with a demonstration of an elegant carotid stenting technique.
Tying things up: what to take home with you!
The “take-home” message of this last afternoon was led by Dr. R. Nogueira, an interesting discussion regarding the common question – when should we stop trying to open a target vessel?
Dr. Nogueira provided us with a remarkable and comprehensive presentation summarizing the different MT techniques, devices and material while discussing different real-life situations.
Even taking into account clots types, number of passes, anatomic variability and different MT techniques, we know it is not always possible to open an occluded vessel – but how many techniques and how many passes should we try during one procedure? There is no single answer and each case needs to be considered individually, however, using BGC in anterior circulation, choosing the longest stent retriever length available, performing push and fluff/active deployment of the stent retriever, waiting patiently for optimal device expansion prior to retrieval, avoiding the usage of large diameter stents in small arteries and using combined local aspiration mainly if MCA curvature or poor opening/device pinching were recommended, all aiming to prevent vessel wall damage and to improve revascularization rates.
See you next year!
…and so, with this comprehensive message, SLICE 2018 came to a close…. You can see the vitality and the dedication that occurred here to share the experience and clinical knowledge necessary to improve and advance stroke care for all.
We hope you have enjoyed these brief glimpses into what was accomplished these three days in Nice, information that you can further expand on this website and we look forward to the future and hope you have found a reason to join us, next year for SLICE 2019!
Shani AVNERY KALMANOVICH
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital